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FOIA Number: 2006-0810-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Subseries:
OA/ID Number:
1228
FolderlD:
Folder Title:
[Working Group Draft Notebook] [1]
Stack:
Row:
Section:
Shelf:
Position:
S
51
6
4
3
�Revised
WORKING GROUP DRAFT
7/15
PRiVILEGEB-AND CONFIDENTIAL
TABLE OF CONTENTS
DETERMINED TO BE AN
ADMINISTRATIVE MARKING
1.
Introductory Overview
INITIALS: J6J)Z— DATE: Q&lSZUCl
2.
Ethical Foundations
3.
Coverage
4.
Guaranteed National Benefit Package
5.
National Health Board/National Administration
6.
State Responsibilities
7.
Regional Health Alliances
8.
Corporate Alliances/ERISA
9.
Health Plans
10.
Risk Adjustment
11.
Rural Communities in the New System
12.
Integration of Workers Compensation and Automobile Insurance
13.
Inter-Alliance Health Security Fund
14.
Budget Development and Enforcement
15.
Quality Management and Improvement
16.
Information Systems and Administrative Simplification
17.
Creating a New Health Workforce
OS/D' F
�WORKING GROUP DRAFT
-PRiVftEOED AND CONFtDENHAL-
TABLE OF CONTENTS (CONTINUED)
18.
Academic Health Centers
19.
Medical Research Initiatives
20.
Public Health Initiatives
21.
Long-Term Care
22.
Malpractice Reform
23.
Antitrust Reform
24.
Fraud and Abuse
25.
Programs For Underserved Populations
26.
Medicare
27.
Medicaid
28.
Government Programs
•
•
•
•
29.
Transition
•
•
•
30.
Department of Defense
Veterans Affairs
Indian Health Service
Federal Employee Health Benefits Plan
State Phase-In
Insurance Reforms
Short-Term Cost Controls
Financing Health Coverage
�Clinton Presidential Records
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�DETERMINED TO AN
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WORKING GROUP DRAFT
-PRIVILEGED AN
THE PROBLEM
Even Americans who are satisfied with their health insurance coverage and care
understand that serious problems exist in the health care system:
•
Americans lack security — One out of four people — or 63 million people - will lose health insurance coverage for some period during the next two
years. Thirty-seven million Americans have no insurance and another 22
million lack adequate coverage.
Losing or changing a job often means losing insurance.
Becoming ill or living with a chronic medical condition can
mean losing insurance coverage or not being able to obtain it.
•
Health care costs are rising faster than other sectors of the economy —
Precipitous growth in health care costs robs workers of wages, fuels the growth
of the federal budget deficit and puts affordable care out of reach for millions
of Americans.
Left unchecked, rising health care costs will consume almost
two-thirds of the increase in Gross Domestic Product for each
American for the rest of the decade. Health care costs will grow
from 14 percent of GDP to 19 percent even without any
expansion of coverage to insure Americans who have no
insurance.
•
Health care bureaucracy overwhelms both consumers and health providers
— Excessive paperwork confuses and frustrates doctors, nurses, patients and
their families.
The bureaucracy treats people like case files and, too often,
leaves them confused about effective treatment and coverage.
Bureaucracy also drives up costs — Almost half of the total
costs involved in running a typical doctor's office or hospital are
administrative expenses.
�WORKING GROUP DRAFT
-PRIVIfcEGED-T^ND-GONFIDENIIAL
Quality is uneven — Because no clear standards define best medical practice,
lack of information and inadequate attention to prevention make the quality of
health care across America uneven. Consumers have no way to judge the
quality of their health care or health plans.
Coverage for long-term care is inadequate — Many elderly and disabled
Americans enter nursing homes and other institutions when they would prefer
to remain at home. Families exhaust their resources trying to provide for
disabled relatives.
Many Americans cannot obtain quality care — In many rural and inner-city
areas, shortages of doctors, clinics and hospitals erect barriers to care.
Fraud and abuse cheat everyone — Many Americans believe that exorbitant
charges, fraud and abuse undermine both quality and access to care.
�omwm 3AiivHisiNii^av
NV 39 01 a3NIWd313Q
WORKING GROUP DRAFT
PRIVILEGED At>lD CONFIDENTI/\^
THE AMERICAN HEALTH SECURITY ACT OF 1993
The American Health Security Act of 1993 guarantees comprehensive health insurance
coverage for all Americans. Health coverage and access to care continue without interruption
even if Americans lose or change jobs, move from one area of the country to another, become
ill or confront a serious illness in the family.
Under the American Health Security Act:
Americans have choice of health plans and providers.
No health plan denies enrollment to any applicant or rejects any participant
because of health, employment or financial status.
No health plan charges some Americans more than others because of their age
or because they are sick or live with a chronic medical condition.
All health plans meet national quality standards.
Americans no longer confront the frustration and lack of basic fairness caused
by confusing coverage, hidden loopholes and fine print.
Physicians, nurses and other health providers are relieved of excessive
administrative burden and over-regulation and allowed to focus on caring for
patients.
Within a federal framework, the American Health Security Act allows each state to
adapt the health care system to local needs and conditions.
CONTROLLING HEALTH CARE COSTS
Provisions of the American Health Security Act bring projected growth in health care
costs down to the rate of personal income growth by 1997. The American Health Security
Act accomplishes this goal by increasing competition in health care, reducing administrative
costs and imposing budget discipline.
•
The American Health Security Act increases competition in health care.
•
Better information and practice guidelines on cost-effective treatments
help physicians and patients make cost conscious choices that also
enhance quality.
�WORKING GROUP DRAFT
-FFTYn FfiFD AKD CONFIDENTIAL
•
Health plans receive fixed premiums based on risk characteristics of
individuals enrolled in their plan. They must provide high quality care
within that premium. Working under a fixed budget, providers and
plans have incentives to spend medical resources cost effectively.
•
A standard, universal package of health benefits and information made
available to consumers about the price and performance of health plans
encourages informed choices about health care, providers and plans.
•
Employers receive tax subsidies only for services covered in the
nationally guaranteed benefit package eliminating tax incentives that
now encourage overspending on health care.
•
Consumers pay less for low cost plans and more for high-cost plans
creating incentives for cost-conscious choice.
•
The American Health Security Act reduces administrative burdens and costs.
•
It places the American health care system under a budget, limiting growth in
spending to the rate of growth in personal income.
If savings attained through competition and reductions in
administrative costs alone do not achieve the national goal of
controlling growth in health care spending, the budget provides a
backstop, ensuring achievement of that critical goal.
Like the private sector, major government programs, including
Medicare and Medicaid, also operate under a budget restraining
the growth of federal and state spending for health care.
•
Malpractice reform reduces costs generated by defensive medicine.
REDUCING BUREAUCRACY
The American Health Security Act reduces the burden of paperwork and
administrative hassles endemic to the health care system.
As a result of health reform, regulatory, billing and reporting requirements imposed on
health care providers decline. Consumers experience a streamlined and simpler system that
features understandable descriptions of health plans and performance, standardized benefits
and no fine print.
�WORKING GROUP DRAFT
--gRI¥IfcEGED~AND CQNriDENTIAL
•
A standard benefit package makes coverage easier to understand.
•
Administrative costs associated with multiple benefit packages and risk
selection are eliminated.
•
Standard forms for insurance reimbursement, the submission of claims and
clinical encounter records simplify paperwork and reduce administrative costs
for providers and patients.
•
The cost of administering health insurance in small companies declines as
health alliances pool purchasing power and the administration for many small
firms and individuals.
•
The need for dual coverage coordination — and disputes among insurance
companies over coverage responsibility — virtually disappears.
•
Federal requirements under Medicare and Medicaid and existing regulatory
laws are streamlined and simplified.
•
Health care coverage for workers' compensation and automobile insurance
merge into the new health system, reducing duplication and waste.
•
An easy-to-navigate system for resolving disputes provides consumers with an
accessible route to getting answers and clarifying problems.
ENHANCING QUALITY
The American Health Security Act improves the quality of American health care by
creating standards and guidelines for practitioners, by re-orienting quality assurance to
measuring outcomes rather than process, by increasing the national commitment to medical
research and by promoting primary and preventive care.
•
Explicit quality goals and standards shape the health care system.
•
Health plans are held accountable for meeting quality standards.
•
Regular publication of accessible information related to quality and cost allows
consumers to make informed choices among health care plans.
•
Enhanced investments in research related to quality outcomes and practice
guidelines advance knowledge in critical areas.
�WORKING GROUP DRAFT
i PRnrtLEGED-ANB-CONFIDENTIAL
•
Consumers have a voice in efforts to improve quality and hold health providers
accountable through consumer surveys and participation on boards of health
alliances and plans.
•
A special funding mechanism ensures that academic health centers continue
their vital role in research, training and specialty care.
•
A new system of incentives emphasizes the training of primary care physicians
and other health professionals.
•
New investments in public health enhance the level of protection for all
Americans.
•
Coverage for a wide range of preventive health measures in the standard
benefit package reduces costs associated with delayed treatment.
EXPANDED COVERAGE FOR LONG-TERM CARE
The American Health Security Act expands the availability of long-term care as well
as increasing its affordability, for disabled Americans, both at home and in the community.
Disabled Americans of all age gain access to a wider variety of home and
community-based support services, making it possible for some individuals to
continue to live at home rather than in nursing homes.
New services support the efforts of families caring for disabled relatives,
providing respite care and assistance.
Requirements that nursing home patients spend down their assets in order to
qualify for coverage under Medicaid are modified.
The amount of monthly income that nursing home residents covered under
Medicaid are allowed to keep increases.
National standards improve the quality and reliability of private long-term care
insurance.
Tax incentives support the development of private long-term
care insurance.
Tax incentives support the efforts of disabled adults to return to work.
8
�WORKING GROUP DRAFT
"PRiVftEGED AI^JD CONFIDENTIAL
EXPANDING THE HEALTH CARE SYSTEM
The American Health Security Act invests in the development of an adequate health
care system in areas with inadequate services. Those investments hold the promise of
improving the availability and quality of health services in rural and inner-city communities,
increasing the number of health providers and guaranteeing the same standards of care across
the nation.
•
Health alliances assume responsibility for building health networks in rural and
urban areas with inadequate access to care.
•
Incentives are provided to attract health professionals to settle in areas with
inadequate care.
•
Common standards for quality enhance care in all regions of the country.
CRACKING DOWN ON FRAUD AND ABUSE
The American Health Security Act cracks down on health care providers and
institutions that impose excessive charges or engage in fraudulent practices. It sets tougher
standards and stiffer penalties for those who abuse the system.
•
New criminal penalties for defrauding health care plans and patients discourage
abuse.
•
New criminal penalties for the paying of bribes or other gratuities block efforts
to influence the delivery of health services and coverage.
•
New civil monetary penalties bar health care providers from submitting false or
fraudulent claims, or otherwise misrepresenting themselves or the services they
provide.
•
Tighter restrictions eliminate referral "kickbacks" in the private sector as well
as for the Medicare and Medicaid programs.
•
New standards prohibit self-referral, the practice of physicians ordering
services delivered at institutions in which they hold financial interests.
•
Accountability standards make fraud or other misbehavior automatic grounds
for exclusion from participating in health plans.
�Clinton Presidential Records
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�DETERMINED TO BE AN
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INITIALS:
DATE: O&teU&l
WORKING GROUP DRAFT
ERIVTT FGEQ-Afin m N n n r . N T T A I ;
ETHICAL FOUNDATIONS OF HEALTH REFORM
The values and principles that shape the new health care system reflect fundamental
national beliefs about community, equality, justice and liberty. These convictions anchor
health reform in shared moral traditions.
UNIVERSAL ACCESS: Every American citizen and legal resident should
have access to health care without financial or other barriers.
COMPREHENSIVE BENEFITS: Guaranteed benefits should meet the full
range of health needs, including primary, preventive and specialized care.
CHOICE: Each consumer should have the opportunity to exercise effective
choice about providers, plans and treatments.
EQUALITY OF CARE: The system should not create two tiers of service but
determine the quality and level of care based only on differences of need, not
individual or group characteristics.
FAIR DISTRIBUTION OF COSTS: The health care system should spread
the costs and burdens of care across the entire community, basing the level of
contribution required of consumers on ability to pay.
PERSONAL RESPONSIBILITY: Under health reform, each individual and
family assumes responsibility for protecting and promoting health and
contributing to the cost of care.
INTER-GENERATIONAL JUSTICE: The health care system should
respond to the unique needs of each stage of life, sharing benefits and burdens
fairly across generations.
WISE ALLOCATION OF RESOURCES: The nation should balance
prudently what it spends on health care against other important national
priorities.
EFFECTIVENESS: The new system should deliver effective care, avoid
ineffective measures and support research that leads to the discovery and
development of effective treatment and new approaches.
10
�WORKING GROUP DRAFT
-PRIVILEGED AMD CONITDENTIAL
QUALITY: The system should deliver high quality care and provide
individuals with the information necessary to make informed health care
choices.
EFFECTIVE MANAGEMENT: Simplifying and continually improving the
health care system and making it easy for both patients and providers to use
reduces administrative costs.
PROFESSIONAL INTEGRITY AND RESPONSIBILITY: The health care
system should treat the clinical judgments of professionals with respect and
protect the integrity of the provider-patient relationship while ensuring that
health-care providers fulfill their responsibilities.
FAIR PROCEDURES: To protect these values and principles, fair and open
democratic procedures must lie behind decisions concerning the operation of
the health care system and the resolution of disputes that arise within it.
LOCAL RESPONSIBILITY: The new health care system must allow states
and local communities working within the framework of national reform to
design an effective, high-quality system of care that serves each of their
citizens.
11
�Clinton Presidential Records
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�DETERMINED TO BE AN
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INITIALS:j£2£s_DATE:
ftg^'^
WORKING GROUP DRAFT
• PRIVILCOED AND CONHDENIIAL
COVERAGE
All eligible Americans are guaranteed access to health services in a nationally defined,
comprehensive package of benefits with no lifetime limits on coverage.
Categories of individuals eligible for guaranteed health coverage:
•
American citizens
•
Nationals
•
Citizens of other countries legally residing in the United
States
•
Long-term non-immigrants.
SOURCES OF HEALTH COVERAGE
Every eligible person receives a Health Security Card entitling him or her to obtain
coverage through a health plan that provides services in the comprehensive benefit package.
Eligible individuals enroll in a health plan through a health alliance unless they are:
Medicare recipients; active duty military personnel covered by the Department of Defense; or
individuals who enroll in the Department of Defense, Department of Veterans Affairs or the
Indian Health Service plans. (See section on "Government Programs," Tab 28.)
Individuals covered under Medicare continue to receive benefits through those
programs. Individuals eligible for Medicaid receive Medicaid coverage through regional
health alliances.
Individuals eligible for health care provided by the Department of Defense,
Department of Veterans Affairs and the Indian Health Service may continue to receive care
through those programs.
All employed persons choose a health plan through a corporate or regional health
alliance. Employees of firms with 5000 or fewer workers become members of a regional
alliance established to serve the area in which they live. Employees of firms with more than
5000 employees obtain coverage through a corporate alliance established by their employer
unless the employer chooses to purchase coverage through the regional alliance.
13
�WORKING GROUP DRAFT
PRIVILEGED AND CONFIDENTIAL
Members of Taft-Hartley plans with more than 5000 members obtain coverage from
an alliance formed by the Taft-Hartley plan. Employees of rural electric and telephone
cooperative plans that include more than 5000 members may receive coverage through a
corporate alliance formed by the cooperative.
All employees of government, including federal, state, local and special-purpose
agencies obtain coverage through the regional alliance where they live. All individuals who
are self-employed or not employed obtain coverage through regional alliances unless they are
eligible for Medicare.
Health coverage continues without interruption for individuals who become
unemployed. Unemployment insurance funds assume payment of the employer's share of
premiums for 26 weeks on behalf of any employee who works at least 20 hours per week for
the preceding four quarters and becomes unemployed.
Alliances provide financial assistance to unemployed workers and their families on the
basis of income, subsidizing all or part of the employee's contribution toward the cost of the
premium, deductibles and co-payments.
If an unemployed individual is covered through a corporate alliance, the unemployed
individual may remain in the corporate alliance for up to one year. The regional alliance
assumes responsibility only for payments up to the average cost of a premium in its health
plans. The corporate alliance may not charge the former employee more than the payment
covered by the regional alliance. After a year, coverage for the former employee moves from
corporate alliance into the regional alliance.
Low-income individuals and families who are not eligible for Medicaid obtain health
coverage through regional alliances with their required contributions toward health premiums
based on income. The cost of co-payments and deductibles for low-income individuals are
also subsidized.
A state that establishes a single-payer system of health coverage may require every
eligible person residing in the state to obtain coverage through one alliance.
Eligible individuals employed in a state that adopts a single-payer system but residing
in another state enroll in an alliance located where they live unless the single-payer state
specifically includes them in the single-payer system.
14
�WORKING GROUP DRAFT
-^RtUILEGEHAND-CONFIDENTIAL
OBTAINING COVERAGE
Individuals obtain health coverage by enrolling in a plan through a regional or
corporate health alliance. The National Health Security card serves as proof of eligibility.
An individual eligible for Medicaid, whether employed or unemployed, continues to
apply for Medicaid coverage at the appropriate office. The Medicaid card serves as proof of
eligibility for coverage through the regional health alliance. Eventually Medicaid recipients
will receive coverage through the alliance. (See "Medicaid" section, Tab 27.)
Individuals over age 65 continue to receive coverage through the Medicare program.
Individuals over the age of 65 but not eligible for Medicare receive coverage through regional
alliances, into which they pay premiums. Depending on income, they may be eligible for
subsidies to pay all or part of the cost of premiums and required cost sharing.
Retirees over the age of 65 who receive health coverage through their former
employers or pension funds continue to receive those benefits. Retired workers and their
spouses under the age of 65 obtain coverage through an alliance only if their former employer
does not have or discontinues an employer-sponsored retirement plan.
ASSURANCE OF COVERAGE
It is the obligation of every eligible individual to enroll in a health plan.
Anyone who does not meet the established deadline for enrollment automatically is
enrolled in a health plan when he or she seeks medical care. Regional alliances assign
patients who do not seek enrollment to a health plan; they automatically assign any newborn
infant who is not enrolled through his or her parents to a plan.
No health plan can cancel an enrollment until the individual enrolls in another plan.
EMPLOYER OBLIGATION
All employers contribute to the purchase of health coverage for their employees and
withhold required contributions from wages on behalf of employees.
15
�WORKING GROUP DRAFT
PRIVILEGED AND CONriDENTIAL
Firms that employ more than 5000 workers ensure that their employees are enrolled in
health plans that meet federal guidelines and report information about enrollment. Employers
with more than 5000 employees that choose to operate corporate alliances pay a premium
surcharge of 1 percent of payroll to the Inter-Alliance Health Security Fund to support the
cost of the health care system.
Large employers may fulfill their obligation to provide coverage by operating a
program of self-insurance through a corporate alliance, contracting with an insurance carrier
or joining the regional alliance. If a large employer merges with a firm in the regional
alliance, it may continue as a corporate alliance. If the number of employees falls below
4800, the employer must join the regional alliance.
PAYMENT OF PREMIUMS
All employers pay 80 percent of the weighted-average premium for health insurance
coverage in the regional alliances which serve their employees or in their corporate alliance.
For small and low-wage employers, the required employer contribution is capped at a
percentage of payroll. (See section on "Financing," Tab 30.)
Employed individuals pay 20 percent of the weighted-average premium for the
average health plan chosen through an alliance. An employee who chooses a less expensive
plan pays less, and an employee who chooses a more expensive plan pays more.
An employer also may pay a larger share of the employee's portion of the premium.
Self-employed and unemployed individuals are responsible for paying the entire
premium unless they are eligible for assistance based on income.
ENFORCEMENT
In conjunction with income-tax reporting, the Secretary of the Treasury requires the
filing of information related to enrollment in a qualified health plan. The Secretary may
require any individual who fails to enroll in a health plan by a specified date to enroll and
pay a penalty in addition to delinquent premiums.
The Secretary of the Treasury also ensures that all employers fulfill the obligation to
provide coverage through a qualified health plan.
16
�WORKING GROUP DRAFT
PRIVILEGED AND CONriDCNTIAb
COORDINATION OF COVERAGE
When an individual obtains necessary medical services outside the geographic area
served by his or her regional or corporate alliance, the plan pays for care under arrangements
established among alliances.
UNDOCUMENTED PERSONS
Undocumented persons are not eligible for the guaranteed health benefit. However,
employers are required to pay health insurance premiums for all of their employees,
regardless of immigration status.
Alliances do not share information related to health insurance premiums paid by
employers with the Immigration and Naturalization Service.
Individuals living in the United States without proper documentation may continue to
use emergency and other health services as provided under current federal law. Health care
institutions that serve a large number of patients who are not eligible for coverage continue to
receive federal funding to compensate for their care.
Any individual not eligible for the national benefit package may purchase coverage
from a private insurance plan to the extent such plans are available.
TERRITORIES
Employed individuals who reside in territories of the United States receive the
comprehensive benefit package through a regional or corporate alliance in the territory.
Employers participate in regional or corporate alliances in the territories under the same rules
and conditions as elsewhere.
OTHERS
Migrant workers receive coverage through the health alliance located in the area of
their permanent residence. If a migrant worker does not have a permanent residence, he or
she receives coverage through the regional alliance that serves the area in which the worker
chooses to enroll in a health plan.
Students living away from home receive coverage through an alliance in the area
where they are enrolled in school.
17
�WORKING GROUP DRAFT
-PRI¥tt£GEB-AND CONffDENHAL
Employees are defined to include not only employees as determined under IRS rules
but broadly enough to discourage employers from designating employees as independent
contractors in order to avoid payment of health insurance premiums. Independent contractors
whose annual income derives over 80 percent from one employer are covered for health
insurance purposes as an employee of that employer.
Part-time employees receive coverage through a regional alliance (working between
10 and 30 hours per week). Employers make a contribution based on a percentage of wages
earned. Individuals employed part time pay the remainder of the premium for the health plan
they choose after contributions from their employers are deducted. They may be eligible for
subsidies, depending on income.
18
�Clinton Presidential Records
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scan such dividers. The title from the original document is
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L
�DETERMINED TO BE AN
ADMINISTRATIVE MARKING
WORKING GROUP DRAFT
, PRIVTI FGFD AND GONFIDENTLAI
GUARANTEED NATIONAL BENEFIT PACKAGE
The health benefits guaranteed to all Americans provide comprehensive coverage,
including mental health services, substance-abuse treatment, some dental services and clinical
preventive services.
The guaranteed benefit package contains no lifetime limitations on coverage, with the
exception of coverage for orthodontia.
MEDICAL SERVICES COVERED
Each health plan must provide coverage for the following categories of services as
medically necessary or appropriate with additional limitations and cost-sharing only as
specified in the American Health Security Act of 1993 or by the National Health Board.
Covered health services are:
Hospital services
Emergency services
Services of physicians and other health professionals
Clinical preventive services
Mental health and substance abuse services
Family planning services
Pregnancy-related services
Hospice
Home health care
Extended-care services
Ambulance services
Outpatient laboratory and diagnostic services
18
�WORKING GROUP DRAFT
--PWViLhGhD ANB-GQNEIDEN33Afc-
Outpatient prescription drugs and biologicals
Outpatient rehabilitation services
Durable medical equipment, prosthetic and orthotic devices
Vision and hearing care
Preventive dental services for children
Health education classes.
DEFINITION OF SERVICES
Hospital services:
•
Inpatient hospital, including bed and board, routine care,
therapeutics, laboratory, diagnostic and radiology services and
professional services specified by the National Health Board
when furnished to inpatients.
•
Outpatient hospital services
•
24-hour a day emergency room services
•
Definition: A hospital is an institution meeting the requirements of
§1861(e) of the Social Security Act.
Services of physician and other health professionals:
•
Includes inpatient and outpatient medical and surgical professional services,
including consultations, delivered by a health professional in home, office, or
other ambulatory care settings, and in institutional settings.
•
Definitions
•
A health professional is someone who is licensed or otherwise
authorized by the State to deliver health services in the State in which
the individual delivers services.
20
�WORKING GROUP DRAFT
•
• PRIVILEGED AND CONFIDENTI AL
Covered services are those that a health professional is legally
authorized to perform in that state. No state may, through licensure
requirements or other restrictions, limit the practice of any class of
health professionals except as justified by the skill or training of such
professional.
The benefit package does not require any plan to reimburse any particular
provider or any type or category of provider. However, each plan is expected
to provide a sufficient mix of providers and specialties and appropriate
locations to provide adequate access to professional services.
Clinical preventive services:
•
Specified in Table I .
•
Limitation: Must be provided as consistent with the periodicity schedule
specified in Table I or as specified by the National Health Board in regulations.
21
�DETERMINED TO BE AN
ADMINISTRATIVE MARKING
INITIALS: KDJL—DATE: ^Jli2iC!S
WORKING GROUP DRAFT
^RIVILEGE&^NDXQMEIDENTIAJu
TABLE I — COVERED CLINICAL PREVENTIVE SERVICES
Age
Tests
Immunizations
0-2
4 DTP, 3 OPV, 3-4 HiB, 1
MMR, 3 HBV
1 Hematocrit, 2 Lead*, 7 Clinician visits'"
3-5
1 DTP, 1 OPV, 1 MMR
1 Urinalysis, 2 Clinician visits'"
6-19
1 Td
Pap/pelvic" every 3 years after menarche, 5
Clinician visits'"
20-39
1 Td every 10 years
Cholesterol every 5 years; Pap/pelvic** every 3
years
40-49
1 Td every 10 years
Cholesterol every 5 years; Pap/pelvic" every 3
1 Td every 10 years
years
Cholesterol every 5 years; Pap/pelvic and
Mammogram every 2 years
50-64
...,
++
65 +
1 Td every 10 years
Cholesterol every 5 years
Pneumococcal - once
Mammogram** every 2 years
Annual influenza
Preventive coverage includes coverage for women of any age presenting for prenatal care.
Key
= For children at high risk for lead exposure only.
= Papanicolaou smears and pelvic exam for females who have reached childbearing
age and are at risk of cervical cancer.
= Once three annual negative smears have been obtained.
= For females of childbearing age at risk for sexually transmitted disease, an annual
Pap smear and screening for chlamydia and gonorrhea.
++
= Females only.
+++
= All visits including immunizations, laboratory tests and other screening tests,
including history, blood pressure measurement, risk assessment, and targeted health
advice/counseling.
DTP = Diphtheria, tetanus, pertussis vaccine
OPV = Oral polio vaccine
HiB
= Haemophilus influenzae type B vaccine
HBV = Hepatitis B vaccine
MMR = Measles, mumps, rubella vaccine
Td
= Tetanus diphtheria toxoid
+
22
|
�DETERMINED TO BE AN
ADMINISTRATIVE MARKING
INITIALS./Pg. DATEOSiai/^i
WORKING GROUP DRAFT
"fRIVILEOCD AND C O ^ ^ N T I A L
7
(Continuation of covered services)
Mental health and substance abuse — inpatient and residential treatment:
•
Inpatient hospital, therapeutic family or group homes, residential
treatment centers, community residential treatment, community
residential treatment and recovery for substance abuse, residential
detoxification services, crisis residential services and other residential
treatment services.
•
Limitations
•
•
Inpatient hospital substance abuse treatment covers only medical
detoxification as required for the management of neuropsychiatric or
medical complications associated with withdrawal from alcohol or
drugs.
•
•
Maximum of 30 days per episode, 60 days annually for all settings in
this category. Health plans upon special appeal may grant an exception
waiver of only the episode maximum for the limited number of cases in
which discharge is not medically appropriate because the patient
continues to make or is at serious risk of making an attempt to harm
them self or to harm others.
Inpatient hospital care for mental and substance abuse disorders is
available only when less restrictive nonresidential or residential services
are ineffective or inappropriate.
Definitions:
•
A hospital is an institution meeting the requirements of §1861(e) or (f)
of the Social Security Act.
•
A residential treatment facility is one which meets criteria for licensure
or certification established by the state in which it is located.
23
�WORKING GROUP DRAFT
•
-PRmLE^DLAmTONFlDENTI-Afc
Eligibility
Persons are eligible for mental health and substance abuse services other than
screening and assessment and crisis services if they have, or have had in the
past year, a diagnosable mental or substance abuse disorder, which meets
diagnostic criteria specified within DSM-III-R, and that resulted in or poses a
significant risk for functional impairment in family, work, school, or
community activities.
•
These disorders include any mental disorder listed in DSM-III-R or
their ICD-9-CM equivalents, or subsequent revisions, with the
exception of DSM-III-R "V" codes (conditions not attributable to a
mental disorder) unless they co-occur with another diagnosable
disorder.
•
Persons who are receiving treatment but without such treatment would
meet functional impairment criteria are considered to have a disorder.
Family members of an eligible participant receiving mental or substance abuse
services may receive medically necessary or appropriately related services in
conjunction with the patient (so-called collateral treatment).
Mental health and substance abuse — professional and outpatient treatment
services:
•
Professional services, diagnosis, medical management, substance abuse
counseling and relapse prevention, outpatient psychotherapy.
•
Limitations
•
Outpatient coverage is limited to 30 visits except clinical management
and substance abuse counseling.
•
Substance abuse and relapse counseling must be provided by
licensed/certified substance abuse providers.
•
Eligibility criteria specified above for inpatient mental health and substance
abuse treatment services apply, except that all persons are eligible for screening
and assessment and 24-hour crisis services.
•
Definitions for services of physicians and other health professionals apply.
24
�WORKING GROUP DRAFT
PRIVILEGED MID CONITDENTIAL
Mental health and substance abuse — intensive non-residential treatment
services:
•
Partial hospitalization, day treatment, psychiatric rehabilitation, ambulatory
detoxification, home-based services, behavioral aide services.
•
Limitations
•
•
•
120 days per year for listed services
Provided only for the purpose of averting the need for, or as an
alternative to, treatment in residential or inpatient settings, or to
facilitate the earlier return of individuals receiving inpatient or
residential care, or to restore the functioning of individuals with serious
mental or substance abuse disorders, or assist individuals to develop the
skills and access the supports needed to achieve their maximum level of
functioning within the community.
Eligibility: As specified for inpatient mental health and substance abuse
treatment services.
Family planning services
Pregnancy-related services
Hospice care:
•
Covered services (as under Medicare):
•
Nursing care provided by or under the supervision of a registered
professional nurse.
•
Medical social services under the direction of a physician.
•
Physicians' services.
•
Counseling services for the purposes of training the individual's family
or other caregiver to provide care and for the purpose of helping the
individual and those caring for him or her to adjust to the individual's
death.
25
�WORKING GROUP DRAFT
-PRIVILEGED AND CONFIDENTIAL
•
•
Medical supplies and the use of medical appliances for the relief of pain
and symptom control related to the individual's terminal illness.
•
Home health aide and homemaker services.
•
•
Short-term inpatient care, although respite care is provided only on an
occasional basis and may not be provided for more than 5 days.
Physical or occupational therapy and speech-language pathology.
Limitations
•
•
•
Only for terminally ill individuals
Only as an alternative to continued hospitalization.
Definition:
•
An individual is considered terminally ill if the
individual has a medical prognosis of a life
expectancy of 6 months or less if the terminal
illness runs its normal course.
Home health care:
•
Same services as under the current Medicare program (including skilled
nursing, physical, occupational and speech therapy, prescribed social services)
with the addition of prescribed home infusion therapy and outpatient
prescription drugs and biologicals.
•
Limitations
•
Only as an alternative to institutionalization (i.e., inpatient treatment in
a hospital, skilled nursing or rehabilitation center) for illness or injury.
•
At the end of each 60 days of treatment, the need for continued therapy
is re-evaluated. Additional periods of therapy are covered only if the
risk of hospitalization or institutionalization exists.
26
�WORKING GROUP DRAFT
TRfVfefeGED-AND CONFIDEN-TIAI^
Extended care services:
•
Inpatient services in a skilled nursing or rehabilitation facility.
•
Limitations
•
Only after an acute illness or injury as an alternative to continued
hospitalization.
•
Maximum of 100 days per calendar year.
Ambulance services:
•
Ground transportation by ambulance, including air transportation by an aircraft
equipped for transporting an injured or sick individual.
•
Limitations
•
Ambulance service is covered only in cases in which the use of an
ambulance is indicated by the individual's condition.
•
Air transport covered only in cases in which other means of
transportation are contra-indicated by the patient's condition.
Outpatient laboratory and diagnostic services:
•
Prescribed laboratory and radiology services, including diagnostic services
provided to individuals who are not inpatients of a hospital, hospice or
extended care facility.
Outpatient prescription drugs and biologicals:
•
Drugs, biological products, and insulin.
•
Limitation:
•
Must be prescribed for use in an outpatient
setting.
27
�WORKING GROUP DRAFT
•
vERmLEGED MID CONFIDENTIAL.
No frequency or quantity limitations other than
reasonable rules for amount to be dispensed and number
of refills. Health plans are permitted to establish
formularies, drug utilization review, generic substitution,
and mail order programs.
Outpatient rehabilitation services:
•
Outpatient occupational therapy, outpatient physical therapy, and outpatient
speech-pathology services for the purpose of attaining or restoring speech.
•
Limitations
•
Coverage only for therapies used to restore functional capacity or
minimize limitations on physical and cognitive functions as a result of
an illness or injury.
•
At the end of each 60 days of treatment, the need for continued therapy
is re-evaluated. Additional periods of therapy are covered only if
function is improving.
Durable medical equipment, prosthetic and orthotic devices:
•
Covered services:
Durable medical equipment
Prosthetic devices (other than dental) which replace all or part of an
internal body organ
Leg, arm, back and neck braces
Artificial legs, arms and eyes (including replacements if required due to
a change in physical condition)
Training for use of above items.
28
�WORKING GROUP DRAFT
•
PRIVILEGED AND COI^tFfDENTIfli:
Limitations
•
Items must improve functional abilities or prevent further deterioration
in function.
•
Does not include custom devices.
Vision and hearing care:
•
Covered services:
•
•
Diagnosis and treatments for defects in vision
•
•
Routine eye exams, including procedures performed to determine the
refractive state of the eyes
Routine ear examinations.
Limitations
•
Eyeglasses and contact lenses limited to children under the age of 18.
•
Routine eye examinations limited to one every 2 years for persons 18
years of age or more.
Preventive dental services for children:
•
Treatment for prevention of dental disease and injury, including maintenance of
dental health, and emergency dental treatment for injury.
•
Limitation: Non-emergency dental services limited to children under age 18.
Health education classes:
Participating health plans are permitted to cover health education or training for
patients that encourage the reduction of behavioral risk factors and promote healthy
activities. Such courses may include smoking cessation, nutritional counseling, stress
management, skin cancer prevention, and physical training classes. Cost sharing is
determined by the plan.
29
�WORKING GROUP DRAFT
-PRIVILEGED AND CONmDENTIAfc
INTEGRATION OF PUBLIC AND PRIVATE MENTAL HEALTH CARE SYSTEMS
The benefit package requires the maintenance of the existing public system for mental
health and substance abuse. It also requires maintenance of the existing block grant program
to the states that supplements their spending on mental and addictive disorder programs.
In order to promote the eventual integration of the public and private systems for
treatment of mental and addictive disorders into a single system of care, states are encouraged
to use the flexibility allowed under health reform to fold their expenditures for public mental
health and substance abuse programs into funding available to regional health alliances to
require integrated care for all health needs, including mental and addictive disorders.
States adopting this direction may obtain a waiver from limits in the benefit package
and are eligible for federal matching funds to develop integrated service systems.
EXCLUSIONS
The benefit package does not cover services that are not medically necessary or
appropriate, private duty nursing, cosmetic orthodontia and other cosmetic surgery, hearing
aids, adult eyeglasses and contact lenses, in vitro fertilization services, sex change surgery and
related services, private room accommodations, custodial care, personal comfort services and
supplies and investigational treatments, except as described below.
COVERAGE OF INVESTIGATIONAL TREATMENTS
Medically necessary or appropriate medical care provided as part of an investigational
treatment during an approved research trial is covered. The intention of this provision is to
cover routine medical costs associated with an investigational treatment that would be
incurred even if the investigational treatment were not administered.
•
An investigational treatment is a treatment the effectiveness of which has not
been determined and which is under clinical investigation as part of an
approved research trial.
30
�WORKING GROUP DRAFT
-PREVHJEGED M i D CONFtPENTIAfc
An approved research trial is a peer-reviewed and approved research program,
as defined by the Secretary of the Department 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 that treatment to be medically necessary or
appropriate.
Coverage is automatically available if the research trial is
approved by the National Institutes of Health, the FDA, the
Department of Veterans Affairs, or a qualified non-governmental
research entity as identified in NIH guidelines.
EXPANSION OF BENEFITS
The initial benefit plan provides comprehensive preventive coverage for all patients
and focuses comprehensive dental, mental health and substance abuse coverage on priority
concerns including preventive dental services for children and treatment for seriously mentally
ill adults, seriously emotionally disturbed children and individuals with substance-abuse
disorders.
The plan proposes to phase in additional benefits in the year 2000. The National
Health Board has discretion to introduce additional benefits earlier if savings from reform and
budget resources permit. Additional benefits included in planned expansion include:
Clinical Preventive Services:
•
Targeted screening tests and vaccinations for high-risk patients (as
defined by the National Health Board): hemoglobin electrophoresis,
tuberculin skin test, rubella antibodies, hearing test, hepatitis B vaccine,
pneumococcal vaccine, influenza vaccine, mammogram, colonoscopy.
•
Periodic medical examinations: every 3 years for individuals ages 2 to
39, every 2 years for adults ages 40 to 65, and annually for adults ages
65 or more.
Dental Services:
•
Preventive dental care extended to adults
•
Restorative services
31
�WORKING GROUP DRAFT
PRIYfcEGED AND CONFIDENTIAt:
•
•
•
Low Cost Sharing — $20 per visit
High Cost Sharing — 40 percent co-insurance, $50 deductible, and
$1500 annual maximum benefit for prevention and restoration
Orthodontia in cases in which it is necessary to avoid reconstructive surgery
•
Low Cost Sharing — $20 per visit
•
High Cost Sharing — 40 percent co-insurance, $50 deductible, and
$2,500 lifetime maximum benefit
Mental Health and Substance Abuse:
•
Improved inpatient coverage, increasing annual maximum benefit from 60 days
to 90 days
•
Elimination, in plans with high cost sharing, of the deductible for inpatient care
equal to charge for one day
•
Elimination of limits on outpatient therapy visits. In plans with high cost
sharing, reduction of cost sharing requirement to 20 percent for initial 12 visits
and 50 percent for subsequent visits. In plans with low cost sharing, reduction
of cost sharing requirement to $10 per visit for initial 12 visits and $25 per
visit for subsequent visits.
•
Coverage for case management with no cost sharing.
Phasing in additional coverage for mental health benefits allows health plans to
develop the skills and capacity to provide a more comprehensive mental health and substance
abuse benefit.
COST SHARING
Consumer out-of-pocket costs for health services in the comprehensive benefit
package is limited, to ensure financial protection, and standardized to ensure simplicity in
choosing among health plans.
Health plans use standard consumer cost sharing requirements. Health plans may offer
consumers one of three cost sharing schedules:
32
�WORKING GROUP DRAFT
-PRIVILCGED AND CONriDENTIAL-
•
Low cost sharing: $10 co-payments for outpatient services; no co-payments
for inpatient services.
•
Higher cost sharing: $200 individual/$400 family deductibles; 20
percent coinsurance; $2000/3000 maximum on out-of-pocket spending.
•
Combination: Plan provides low cost sharing if enrollees use preferred
providers and higher cost sharing (20 percent coinsurance) if they use
out-of-network providers.
33
�DETERMINED TO BE AN
ADMINISTRATIVE MARKING
IHITlAl S i\>9
WORKING GROUP DRAFT
nATErOB I SK//QCj
•PRP»TLCGED AND CONriDENTIAL
LOW COST SHARING
Cost-sharing
Overall
- Deductible
- Coinsurance
- Out-of-pocket max
Limitations
None
$10 per visit
None necessary
Inpatient Hospital
Full coverage
Professional services, outpatient
hospital services.
$10 per visit
Emergency services
$25 per visit
Waived in emergency.
Preventive services, including
well-baby, prenatal
Full coverage
Services limited to
periodicity in Table 1.
Hospice
Full coverage
As hospital alternative for
terminally ill.
Home health care
Full coverage
As inpatient alternative;
coverage reassessed at 60
days; added coverage only
to prevent instit.
Extended care facilities (SNFs,
rehab facility)
Full coverage
As hospital alternative;
100 day limit.
Outpatient physical, occupational,
speech therapy
$10 per visit
Only to restore function or
minimize limitations from
illness or injury;
reassessment at 60 days;
additional coverage only if
improving.
DME, outpatient lab, ambulance
Full coverage
Routine eye and ear exams,
eyeglasses
$10 per exam or
1 set glasses
34
Private room only when
medically necessary
Eyeglasses limited to
children only
|
�WORKING GROUP DRAFT
Dental services
-Initial: Prevention
-PRIVILEGED AND CONFIDENTIAL
$10 per visit
-Additions in 2000:
For <18 only
Remove age limit on
prevention
Restoration
$20 per visit
Orthodontia
$20 per visit
Prescription drugs
Only to avoid
reconstructive surgery
$5/prescription
Mental health / substance abuse
Initial
Inpatient services:
Full coverage
30 day/episode; 60
day/year max
Hospital alternatives:
Full coverage
All outpatient except
psychotherapy:
$10 per visit
Psychotherapy:
120 days maximum
no limits
$25 per visit
30 visits maximum
Full coverage
30 day/episode; 90
day/year max
Full coverage
120 days maximum
$10 per visit
no limits
$25 per visit
no limits
2000
Inpatient services:
Hospital alternatives:
Outpatient incl. 1-12
psychotherapy visits:
12+ psych visits:
35
l
�DETERMINED TO BE AN
ADMINISTRATIVE MARKING
WORKING GROUP DRAFT
•gRWILEOCD AND CONFIDENTIAL
HIGH COST SHARING
Cost-sharing
Overall
- Deductible
- Coinsurance
- Out-of-pocket max
Individual
Family
Limitations
$200/400
indiv/family
20%
$2,000
$3,000
Inpatient Hospital
20% co-ins
Professional services, outpatient
hospital services including
emergency.
20% co-ins
Preventive services, including
well-baby, prenatal
Co-ins and
deductible does
not apply
Private room only when
medically necessary
Services limited to
periodicity in Table 1.
Hospice
20% co-ins
As hospital alternative for
terminally ill.
Home health care
20% co-ins
As inpatient alternative;
coverage reassessed at 60
days; added coverage only
to prevent instit.
Extended care facilities (SNFs,
rehab facility)
20% co-ins
As hospital alternative;
100 day limit.
Outpatient physical, occupational,
speech therapy
20% co-ins
Only to restore function or
minimize limitations from
illness or injury;
reassessment at 60 days;
additional coverage only if
improving.
DME, outpatient lab, ambulance
20% co-ins
Routine eye and ear exams,
eyeglasses
20% co-ins
36
Eyeglasses limited to
children only
�WORKING GROUP DRAFT
Dental services
-Initial: Prevention
-PRIVILCOED AND CONFIDENTIAL
20% co-ins
-Additions in 2000:
Restoration
Orthodontia
Prescription drugs
For <18 only
Remove age limit on
prevention
$50 deduc +
40% co-ins
40% co-ins
$1500 annual max
Only to avoid
reconstructive surgery;
$2500 lifetime max
$250/year deduc
20% co-ins
oop max applies
Mental health / substance abuse
Initial
Inpatient services:
1 day deductible
20% co-ins; oop max
applies
30 day/episode; 60
day/year max
1 day deductible
20% co-ins
120 days maximum
20% co-ins
no limits
50% cost sharing
30 visits maximum
20% co-ins; oop max
applies
30 day/episode; 90
day/year max
20% co-ins
120 days maximum
20% co-ins
no limits
50% cost sharing
no limits
Hospital alternatives:
All outpatient except
psychotherapy:
Psychotherapy:
2000
Inpatient services:
Hospital alternatives:
Outpatient incl. 1-12
psychotherapy visits:
12+ psych visits:
37
�DETERMINED TO BE AN
ADMINISTRATIVE MARKING
INITIAIRrfrCDt, HATP- GS
WORKING GROUP DRAFT
-PRIVILCOCD AI'JD CONFIDENTIAL
COMBINATION COST SHARING
Services (with same limitations as
above)
Overall
- Deductible
- Coinsurance
- Out-of-pocket max
In network
Out of network
None
$200/400
indiv/family
20%
$10 per visit
None necessary
$2,000
$3,000
Inpatient Hospital
Full coverage
20% co-ins
Professional services, outpatient
hospital services.
$10 per visit
20% co-ins
Emergency services
$25 per visit
20% co-ins
Preventive services, including
well-baby, prenatal
Full coverage
Full coverage
Hospice
Full coverage
20% co-ins
Home health care
Full coverage
20% co-ins
Extended care facilities (SNFs,
rehab facility)
Full coverage
20% co-ins
Outpatient physical, occupational,
speech therapy
$10 per visit
20% co-ins
DME, outpatient lab, ambulance
Full coverage
20% co-ins
$10 per exam or
1 set glasses
20% co-ins
$10 per visit
20% co-ins
Restoration
$20 per visit
$50 deduc +
40% co-ins
Orthodontia
$20 per visit
40% co-ins
Routine eye and ear exams,
eyeglasses
Dental services
-Initial: Prevention
-Additions in 2000:
38
0
jMiO !
�WORKING GROUP DRAFT
•PRIVILEGED AND GONFIDENTIAE
Prescription drugs
$5/prescription
$250/year deduc
20% co-ins
oop max applies
Mental health / substance abuse
Initial
Inpatient services:
Full coverage
1 day deductible
20% co-ins; oop max
applies
Full coverage
1 day deductible
20% co-ins
$10 per visit
20% co-ins
$25 per visit
50% cost sharing
Full coverage
20% co-ins; oop max
applies
Full coverage
20% co-ins
$10 per visit
20% co-ins
$25 per visit
50% cost sharing
Hospital alternatives:
All outpatient except
psychotherapy:
Psychotherapy:
2000
Inpatient services:
Hospital alternatives:
Outpatient incl. 1-12
psychotherapy visits:
12+ psych visits:
—
39
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
£
�DETERMINED TO BE AN
ADMINISTRATIVE MARKING
WORKING GROUP DRAFT
^-pprvu n r r n nvn rr^frrn^MTT A y _
NATIONAL HEALTH BOARD
The American Health Security Act creates an independent National Health Board
responsible for setting national standards and overseeing the establishment and administration
of the new health system by states.
The National Health Board and existing executive agencies divide responsibility for
administration of the new health care system.
AUTHORITY OF THE NATIONAL HEALTH BOARD
The Board may contract with other agencies or entities, at the Board's discretion, to
obtain the information and expertise it needs to fulfill its responsibilities. The Board may
also establish advisory committees to assist it in performing any of is duties.
The Board undertakes the following functions:
•
Oversight of State Systems
The Board establishes requirements for state plans, provides technical
assistance, monitors compliance with federal standards and ensures access to
health care for all Americans.
[HHS position: HHS would oversee state systems.]
•
Comprehensive Benefit Package
The Board interprets and updates the nationally guaranteed benefit package and
issues regulations. The Board may recommend to the President and Congress
appropriate adjustments to the nationally guaranteed benefit package to reflect
changes in technology, health care needs and methods of service delivery.
•
Budgets
The Board issues regulations concerning implementation of the national budget
for health care spending and enforces the budget.
The board establishes baseline budgets for alliances by allocating
national spending to alliances to reflect regional variations.
39
�WORKING GROUP DRAFT
PRIVILEGED AND CONriDENTIAL
The Board certifies compliance with the budget. See section
entitled "Budget Development and Enforcement" at Tab 14 for a
description of this process.
National Quality Management System
The Board establishes and manages a performance-based system of quality
management and improvement described in the section entitled "Quality
Management and Improvement" at Tab 15. The Board develops measures to
be used in the annual quality performance report of health plans. In developing
these measures, the Board consults with appropriate parties, including
providers, consumers, health plans, states, purchasers of care, and experts in
law, medicine, economics, public health, and health services research including
appropriate agencies such as AHCPR, NIH and HCFA.
To measure quality, the Board develops and implements standards to establish
a National Health Information System as described in the section on
"Information Systems and Administrative Simplification" at Tab 16.
[HHS alternative: Quality Report Card
The Secretary of HHS administers the quality program. The Department's
functions include: (1) establishing a quality assurance program with each state;
(2) establishing a monitoring system to assure state compliance; (3) performing
research on quality measures; and (4) conducting annua consumer satisfaction
surveys. The Secretary provides information on quality from the surveys and
national information system to the Board, states, alliances, plans and
consumers.]
Decisions on benefits and quality by the National Health Board also apply to corporate
alliances.
MEMBERSHIP
The National Health Board consists of seven members appointed by the President by
and with the advice and consent of the Senate. At least one of the members represents the
interests of states.
41
�WORKING GROUP DRAFT
-TRIVILEGED AJ^D-CONFIDENTIAL
The President designates one member as chairman. The chairman serves a term
concurrent with that of the President and serves at the pleasure of the President. The
chairman may serve a maximum of three terms.
The other members serve staggered four year terms. These members may be
reappointed for one additional term. The President may remove a member for neglect of duty
or malfeasance in office.
When a vacancy occurs, other than by expiration of term, the President appoints a
successor to serve the remainder of the term. A vacancy in the membership of the Board
does not impair the right of the remaining members to exercise all powers of the Board. The
Board designates a member to act as chairman during any period when no chairman is
designated by the President.
Upon expiration of a term of office, a member continues to serve until a successor is
appointed and qualified. The President has the power to fill all vacancies that occur on the
Board during the recess of the Senate by granting commissions that expire with the next
session of the Senate.
QUALIFICATIONS
The President nominates Board members on the basis of their experience and expertise
in relevant subjects, including health care finance and delivery, state health systems, consumer
protection, business, law or delivery of care to vulnerable populations. Members of the
National Health Board must be citizens of the United States.
During the term of appointment. Board members serve as employees of the federal
government and can hold no other employment. A member of the Board may not have a
pecuniary interest in or hold an official relation to any health care plan, health care provider,
insurance company, pharmaceutical company, medical equipment company or other affected
industry. Before assuming an appointment to the National Health Board, the prospective
member must certify under oath that he or she has complied with this requirement.
After leaving the Board, former members are subject to post-employment restrictions
applicable to comparable federal employees.
42
�WORKING GROUP DRAFT
-PRIVILEGED AND CONFIDENTIAL
OPERATION OF THE BOARD
The National Health Board appoints and sets the compensation of an executive
director. The Board also appoints additional officers and employees, subject to applicable
civil service rules, as necessary to carry out its functions. The Board hires sufficient staff to
carry out the functions described above.
The Board establishes advisory committees. Advisory committees include
representatives of states, health providers, employers, consumers and affected industries.
The Board may contract, with the Department of Health and Human Services and
other governmental and nongovernmental bodies, for the conduct of research and analysis as
required to execute its responsibilities. The Board has access to all relevant information and
data available from appropriate federal departments and agencies. It coordinates its activities,
particularly the conduct of original research and associated studies, with the activities of
appropriate federal agencies.
The Board prepares and sends to the President and Congress an annual report
addressing the overall implementation of the new health care system, including federal and
state implementation, data related to quality improvement and other issues. The annual report
includes recommendations for changes in the administration, regulation and laws related to
health care and coverage, as well as a full account of actions taken by the Board during the
previous year.
The Office of Management and Budget reviews the Board's budget, which is submitted
to Congress in conjunction with the President's budget. The Office of Management and
Budget does not review regulations issued by the Board or its annual report to Congress prior
to publication.
The General Accounting Office conducts periodic audits of the Board.
RESPONSIBILITIES OF DEPARTMENT OF HEALTH AND HUMAN SERVICES
The Department of Health and Human Services continues to administer its existing
programs, such as Medicaid, Medicare and the Public Health Service.
The Department of Health and Human Services also administers and implements those
aspects of the new health care system not delegated to the National Health Board or any other
federal department.
43
�DETERMINED TO BE AN
ADMINISTRATIVE MARKING
INIT!ALS«Slit—DATE:<2^^9
WORKING GROUP DRAFT
-FRF/HXGCD Af'JD CONFIDENTIAt:
NATIONAL ADMINISTRATION
The National Health Board reviews plans submitted by the states describing the
implementation of the new health care system. [HHS position: HHS would do this.]
Corporate alliances are supervised through ERISA and the Department of Labor. (See
"Corporate Alliances/ERISA.")
In the event that a state fails to meet the deadline for establishing regional health
alliances, or fails to operate the alliance system in compliance with federal requirements, the
National Health Board ensures that all eligible individuals have access to services covered in
the comprehensive benefit package.
To induce a state to act, the National Health Board informs the Secretary of the
Department of Health and Human Services of a state's non-compliance. The Secretary has
the authority to order the withholding of federal health appropriations.
The National Health Board has the authority to certify to the Secretary of the Treasury
that a state is not in compliance with requirements established in federal law. In such a case,
the Secretary of the Treasury may deny employers located in that state the right to deduct a
specified portion of contributions for health insurance from taxable income.
If a state persists in its failure to comply with federal requirements, the National
Health Board informs the Secretary of the Department of Health and Human Services. The
Secretary is required to take one of the following actions to ensure that all eligible individuals
have access to nationally guaranteed health benefits:
•
Dissolve an existing health alliance and establish one or more regional
alliances in compliance with federal requirements
•
Contract with private parties or others to establish and operate regional
alliances
•
Order regional alliances or health plans to comply with specific federal
requirements
•
Take other steps as needed to assure coverage.
An alliance operating under the supervision of the Secretary of the Department of
Health and Human Services is responsible for meeting all requirements imposed on regional
health alliances.
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When a state demonstrates to the National Health Board that it is prepared to resume
its statutory responsibilities, the state may establish its own alliances or take over
management of alliances established under federal supervision.
45
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
k
�DETERMINED TO BE AN
ADMINISTRATIVE MARKING
INITIALS: fl)f, D A T E ^ f e / ^ / ^
WORKING GROUP DRAFT
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STATE RESPONSIBILITIES
States assume responsibility for ensuring that all eligible individuals have access
through a health alliance to a health plan that delivers the nationally guaranteed
comprehensive benefit package.
STATE PLANS
Each state submits to the National Health Board a plan for implementation of health
reform, demonstrating that its health care system meets all requirements under federal law.
States periodically update the plan, as required by the National Health Board.
State plans designate an agency or official charged with coordinating the state
responsibilities under federal law and delegating those responsibilities to state agencies or
entities.
The plan also describes how the state intends to perform each of the following
functions:
Allocation and monitoring of the budget for health care spending when
the state assumes responsibility for the budget.
Administration of subsidies for low-income individuals and families.
Certification of health plans.
Financial regulation of health plans.
Administration of data collection and quality management and
improvement program.
Establishment and governance of health alliances.
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ESTABLISHMENT OF ALLIANCES
No later than January 1, 1996, each state must establish one or more regional health
alliances responsible for providing health coverage to residents in every area of the state.
The state ensures that all eligible individuals enroll in a regional or corporate alliance
and that all alliances offer health plans that provide the comprehensive benefit package. The
state also ensures that each alliance enrolls all eligible persons in the geographic area covered
by the alliance.
ALLIANCE SIZE AND POPULATION
The geographic area assigned to each regional alliance must encompass a population
large enough to ensure that it exercises adequate market leverage in negotiating with health
plans. States may establish one, and only one, regional alliance in each area.
The state may not establish boundaries for health alliances that concentrate racial or
ethnic minority groups, socio-economic groups or Medicaid beneficiaries. An alliance may
not subdivide a primary metropolitan statistical area, but an alliance that covers a
Consolidated Statistical Metropolitan Area within a state is presumed to be in compliance
with these requirements.
An alliance may not cross state lines, but two or more contiguous states may agree to
coordinate the operation of alliances. Coordination may include adoption of joint operating
rules, contracting with health plans, enforcement activities and establishment of fee schedules
for health providers.
OPERATION OF ALLIANCES
A regional alliance may operate as a non-profit corporation, an independent state
agency or an agency of the state executive branch.
A board of directors governs regional alliances that are non-profit corporations.
States establish a mechanism for selecting members of alliance boards and describe the
mechanism in implementation plans submitted to the National Health Board.
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�WORKING GROUP DRAFT
-ERj-VIkBGED-AND GOf^WDENTIAL
The board of each alliance has an even number of employer and consumer
representatives, plus one additional member to serve as chair. The board must include the
following:
•
Employers whose employees purchase health coverage through the
alliance.
•
Employees who purchase through the alliance.
•
Self-employed individuals who purchase through the alliance.
•
Other individuals who obtain coverage through the alliance.
The board of directors of an alliance may not include members of the following
groups or their immediate families:
•
Health care providers or their employees, owners of health plans or their
employees, or other persons who derive substantial income from health
plans or the provision of health care.
•
Members of associations, law firms or other institutions or organizations
that represent the interests of health care providers, health plans or
others involved in the health care field, or who practice as a
professional in an area involving health care.
•
Owners, employees, board members or individuals who derive
substantial income from pharmaceutical companies and suppliers of
medical equipment, devices and services.
To make alliances accountable to consumers and employers, states may establish
statewide councils composed of representatives of employer and consumer organizations to
prepare a list of nominees for alliance boards.
States require each alliance to provide an ombudsman to assist consumers in dealing
with problems that arise with health plans and the alliance. States may also permit consumers
at annual enrollment to check off whether they want a dollar of their premium to go to
support work by alliances' consumer representatives and the office of the ombudsman.
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In addition to a board of directors or advisory board, each regional alliance establishes
a Provider Advisory Board made up of representatives of health care professionals who
practice in health plans administered by the alliance.
In the case of a health alliance that is a state agency or an independent state entity
administered by a state-appointed authority, an advisory board consisting of representatives of
the same groups is appointed to provide advice to the agency.
RISK ADJUSTMENT
States must ensure that each alliance establishes a risk-adjustment mechanism that
complies with the federal standard. Risk-adjustment mechanisms account for differences in
patient populations related to age, gender, family size, health status and services to
disadvantaged populations. (See section on "Risk Adjustment," Tab 10.)
STATE REGULATION OF PLANS
States qualify health plans to participate in alliances. Each state establishes a
mechanism to assess the quality of health plans, their financial stability and capacity to
deliver the comprehensive benefit package to the proper geographic market of each plan.
Only plans qualified by the state may offer health coverage through alliances.
States define requirements related to levels of service and the geographic distribution
of service required of health plans to ensure adequate choice for all eligible participants,
including residents of low-income areas and areas in which the health care system is
inadequate. To provide consumers the opportunity to purchase a plan at the weightedaverage premium, a state must either require at least some plans to cover the entire alliance
area, or provide a subsidy that allows consumers to pay only the weighted-average premium.
Where no plan applies, the state must assure that at least one health plan is available
for every eligible individual residing within its service area.
States may not discriminate against health plans on the basis of location.
A state may not regulate premium rates charged by health plans, except when
necessary to meet budget requirements or regulate plan solvency. (See section on "Budget
Development and Enforcement," Tab 14.)
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PRIVILEGED AND CONriDENTIAL
SOLVENCY AND FISCAL OVERSIGHT
Each state establishes capital standards for health plans that meet minimum federal
requirements established by the National Health Board in consultation with the states.
The minimum capital requirement consists of $500,000. Additional capital may be
required for factors likely to affect the financial stability of health plans, including:
Projected enrollment, number of providers and rate of growth.
Market share and strength of competition.
Degree and approach to risk sharing with providers and financial
stability of providers.
Structure of the plan and degree of integration.
Prior performance of plan, risk history and liquidity of its assets.
Each state defines financial reporting and auditing requirements and requirements for
fund reserves adequate to monitor the financial status of plans.
States designate an agency that assumes control if a health plan fails. Procedures
established by states to handle the failure of health plans assures continuity of coverage for
consumers enrolled in the plan.
GUARANTY FUNDS
Each state has a guaranty fund to provide financial protection to health care providers
and others if a health plan becomes insolvent. States may use existing guaranty fund
arrangements provided that the arrangement meets national standards.
Guaranty funds pay health providers and others if a health plan is unable to meet its
obligations. Guaranty funds cover liability for services rendered prior to health plan
insolvency and for services to patients after the insolvency but prior to their enrollment in
other health plans. Guaranty funds are liable at least for payment of all services rendered by
a health plan for the comprehensive benefit package, including any supplemental coverage for
cost sharing provided by the health plan.
50
�WORKING GROUP DRAFT
PRIVILEGED AND CONFIDENTIAL
If a health plan cannot meet its financial obligations to health care providers, the
providers have no legal right to seek payment from patients for any services covered in the
comprehensive benefit package other than the patients' obligations under cost-sharing
arrangements.
If a health plan fails, health providers are required to continue caring for patients until
they are enrolled in a new health plan.
All health plans must participate in a guaranty fund, and the fund is liable for all
claims against the plan by health care providers, contractors, employees, governments or any
other claimants. The guaranty fund stands as a creditor for any payments made on behalf of
a plan.
If a health plan fails, the state may assess payments of up to 2 percent of premiums on
other plans within the alliance to generate sufficient revenue to cover outstanding claims
against the failed plan. The failure of a health plan is defined as the imminent inability to
pay legitimate claims.
A guaranty fund has the ability to borrow funds against future assessments in order to
meet the obligations of the failed plan.
ADDITIONAL BENEFITS
Any state may provide health benefits in addition to those required under the
nationally guaranteed package. However, in order to expand benefits, a state must
appropriate revenue from sources other than those established by the American Health
Security Act to support delivery of the nationally guaranteed benefit. A state may not rely on
a payroll tax on employers or another revenue source focusing solely on corporations.
SINGLE-PAYER OPTION
A state may establish a single-payer health care system rather than an alliance system
offering multiple plans. A state may establish a single-payer alliance for part of the state.
A single-payer system is one in which the state or its designated agency makes all
payments to health care providers with no intermediaries, health plans or other entities
assuming financial risk. However, providers, such as HMOs, networks of physicians and
hospitals, assume risk by accepting capitated payments to cover the health needs of
individuals.
51
�WORKING GROUP DRAFT
-PRIV-ILEGED-AND-GONHDENTIAir-
A single-payer system provides, at a minimum, the health services defined in the
comprehensive benefit package and impose requirements for co-insurance, co-payments,
deductibles and out-of-pocket limits no greater than those charged by regional alliances.
Single-payer systems also must comply with requirements for quality management and
improvement, the collection of health data and other guidelines for health plans and alliances.
If a state chooses to establish a single-payer health system, the federal government
may waive any of the following requirements under the alliance system:
•
ERISA rules governing corporate alliances
•
Rules delineating participation in regional and corporate alliances
•
Rules continuing Medicare and Medicaid as separate programs outside
the alliance structure consistent with requirements for the protection of
Medicare and Medicaid recipients
•
Guaranty fund rules
A single-payer system established by a state may eliminate cost-sharing requirements;
however, a state must appropriate revenue from sources other than those established by this
Act to support delivery of the nationally guaranteed benefit.
52
�
Dublin Core
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Title
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Health Care Reform
Identifier
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2006-0810-F
Description
An account of the resource
<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[Working Group Draft Notebook] [1]
Creator
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Health Care Task Force
General Files
Identifier
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2006-0810-F Segment 1
Is Part Of
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Box 53
<a href="http://clinton.presidentiallibraries.us/items/show/36144" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12090749" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
5/5/2015
Source
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42-t-2194630-20060810F-Seg1-053-001-2015
12090749