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Title II — Finances

H.R. 676 · 113th Congress · Feb 13, 2013 · Lineage

II Finances

A Budgeting and Payments

Sec. 201 Budgeting process

(a)
Establishment of operating budget and capital expenditures budget—
(1)
In general— To carry out this Act there are established on an annual basis consistent with this title—
(A)
an operating budget, including amounts for optimal physician, nurse, and other health care professional staffing;
(B)
a capital expenditures budget;
(C)
reimbursement levels for providers consistent with subtitle B; and
(D)
a health professional education budget, including amounts for the continued funding of resident physician training programs.
(2)
Regional allocation— After Congress appropriates amounts for the annual budget for the Medicare For All Program, the Director shall provide the regional offices with an annual funding allotment to cover the costs of each region’s expenditures. Such allotment shall cover global budgets, reimbursements to clinicians, health professional education, and capital expenditures. Regional offices may receive additional funds from the national program at the discretion of the Director.
(b)
Operating budget— The operating budget shall be used for—
(1)
payment for services rendered by physicians and other clinicians;
(2)
global budgets for institutional providers;
(3)
capitation payments for capitated groups; and
(4)
administration of the Program.
(c)
Capital expenditures budget— The capital expenditures budget shall be used for funds needed for—
(1)
the construction or renovation of health facilities; and
(2)
for major equipment purchases.
(d)
Prohibition against co-Mingling operations and capital improvement funds— It is prohibited to use funds under this Act that are earmarked—
(1)
for operations for capital expenditures; or
(2)
for capital expenditures for operations.

Sec. 202 Payment of providers and health care clinicians

(a)
Establishing global budgets; monthly lump sum—
(1)
In general— The Medicare For All Program, through its regional offices, shall pay each institutional provider of care, including hospitals, nursing homes, community or migrant health centers, home care agencies, or other institutional providers or pre-paid group practices, a monthly lump sum to cover all operating expenses under a global budget.
(2)
Establishment of global budgets— The global budget of a provider shall be set through negotiations between providers, State directors, and regional directors, but are subject to the approval of the Director. The budget shall be negotiated annually, based on past expenditures, projected changes in levels of services, wages and input, costs, a provider’s maximum capacity to provide care, and proposed new and innovative programs.
(b)
Three payment options for physicians and certain other health professionals—
(1)
In general— The Program shall pay physicians, dentists, doctors of osteopathy, pharmacists, psychologists, chiropractors, doctors of optometry, nurse practitioners, nurse midwives, physicians’ assistants, and other advanced practice clinicians as licensed and regulated by the States by the following payment methods:
(A)
Fee for service payment under paragraph (2).
(B)
Salaried positions in institutions receiving global budgets under paragraph (3).
(C)
Salaried positions within group practices or non-profit health maintenance organizations receiving capitation payments under paragraph (4).
(2)
Fee for service—
(A)
In general— The Program shall negotiate a simplified fee schedule that is fair and optimal with representatives of physicians and other clinicians, after close consultation with the National Board of Universal Quality and Access and regional and State directors. Initially, the current prevailing fees or reimbursement would be the basis for the fee negotiation for all professional services covered under this Act.
(B)
Considerations— In establishing such schedule, the Director shall take into consideration the following:
(i)
The need for a uniform national standard.
(ii)
The goal of ensuring that physicians, clinicians, pharmacists, and other medical professionals be compensated at a rate which reflects their expertise and the value of their services, regardless of geographic region and past fee schedules.
(C)
State physician practice review boards— The State director for each State, in consultation with representatives of the physician community of that State, shall establish and appoint a physician practice review board to assure quality, cost effectiveness, and fair reimbursements for physician delivered services.
(D)
Final guidelines— The Director shall be responsible for promulgating final guidelines to all providers.
(E)
Billing— Under this Act physicians shall submit bills to the regional director on a simple form, or via computer. Interest shall be paid to providers who are not reimbursed within 30 days of submission.
(F)
No balance billing— Licensed health care clinicians who accept any payment from the Medicare For All Program may not bill any patient for any covered service.
(G)
Uniform computer electronic billing system— The Director shall create a uniform computerized electronic billing system, including those areas of the United States where electronic billing is not yet established.
(3)
Salaries within institutions receiving global budgets—
(A)
In general— In the case of an institution, such as a hospital, health center, group practice, community and migrant health center, or a home care agency that elects to be paid a monthly global budget for the delivery of health care as well as for education and prevention programs, physicians and other clinicians employed by such institutions shall be reimbursed through a salary included as part of such a budget.
(B)
Salary ranges— Salary ranges for health care providers shall be determined in the same way as fee schedules under paragraph (2).
(4)
Salaries within capitated groups—
(A)
In general— Health maintenance organizations, group practices, and other institutions may elect to be paid capitation payments to cover all outpatient, physician, and medical home care provided to individuals enrolled to receive benefits through the organization or entity.
(B)
Scope— Such capitation may include the costs of services of licensed physicians and other licensed, independent practitioners provided to inpatients. Other costs of inpatient and institutional care shall be excluded from capitation payments, and shall be covered under institutions’ global budgets.
(C)
Prohibition of selective enrollment— Patients shall be permitted to enroll or disenroll from such organizations or entities without discrimination and with appropriate notice.
(D)
Health maintenance organizations— Under this Act—
(i)
health maintenance organizations shall be required to reimburse physicians based on a salary; and
(ii)
financial incentives between such organizations and physicians based on utilization are prohibited.

Sec. 203 Payment for long-term care

(a)
Allotment for regions— The Program shall provide for each region a single budgetary allotment to cover a full array of long-term care services under this Act.
(b)
Regional budgets— Each region shall provide a global budget to local long-term care providers for the full range of needed services, including in-home, nursing home, and community based care.
(c)
Basis for budgets— Budgets for long-term care services under this section shall be based on past expenditures, financial and clinical performance, utilization, and projected changes in service, wages, and other related factors.
(d)
Favoring non-Institutional care— All efforts shall be made under this Act to provide long-term care in a home- or community-based setting, as opposed to institutional care.

Sec. 204 Mental health services

(a)
In general— The Program shall provide coverage for all medically necessary mental health care on the same basis as the coverage for other conditions. Licensed mental health clinicians shall be paid in the same manner as specified for other health professionals, as provided for in section 202(b).
(b)
Favoring community-Based care— The Medicare For All Program shall cover supportive residences, occupational therapy, and ongoing mental health and counseling services outside the hospital for patients with serious mental illness. In all cases the highest quality and most effective care shall be delivered, and, for some individuals, this may mean institutional care.

Sec. 205 Payment for prescription medications, medical supplies, and medically necessary assistive equipment

(a)
Negotiated prices— The prices to be paid each year under this Act for covered pharmaceuticals, medical supplies, and medically necessary assistive equipment shall be negotiated annually by the Program.
(b)
Prescription drug formulary—
(1)
In general— The Program shall establish a prescription drug formulary system, which shall encourage best-practices in prescribing and discourage the use of ineffective, dangerous, or excessively costly medications when better alternatives are available.
(2)
Promotion of use of generics— The formulary shall promote the use of generic medications but allow the use of brand-name and off-formulary medications.
(3)
Formulary updates and petition rights— The formulary shall be updated frequently and clinicians and patients may petition their region or the Director to add new pharmaceuticals or to remove ineffective or dangerous medications from the formulary.

Sec. 206 Consultation in establishing reimbursement levels

Reimbursement levels under this subtitle shall be set after close consultation with regional and State Directors and after the annual meeting of National Board of Universal Quality and Access.

B Funding

Sec. 211 Overview: funding the Medicare For All Program

(a)
In general— The Medicare For All Program is to be funded as provided in subsection (c)(1).
(b)
Medicare For All Trust Fund— There shall be established a Medicare For All Trust Fund in which funds provided under this section are deposited and from which expenditures under this Act are made.
(c)
Funding—
(1)
In general— There are appropriated to the Medicare For All Trust Fund amounts sufficient to carry out this Act from the following sources:
(A)
Existing sources of Federal Government revenues for health care.
(B)
Increasing personal income taxes on the top 5 percent income earners.
(C)
Instituting a modest and progressive excise tax on payroll and self-employment income.
(D)
Instituting a modest tax on unearned income.
(E)
Instituting a small tax on stock and bond transactions.
(2)
System savings as a source of financing— Funding otherwise required for the Program is reduced as a result of—
(A)
vastly reducing paperwork;
(B)
requiring a rational bulk procurement of medications under section 205(a); and
(C)
improved access to preventive health care.
(3)
Additional annual appropriations to Medicare For All Program— Additional sums are authorized to be appropriated annually as needed to maintain maximum quality, efficiency, and access under the Program.

Sec. 212 Appropriations for existing programs

Notwithstanding any other provision of law, there are hereby transferred and appropriated to carry out this Act, amounts from the Treasury equivalent to the amounts the Secretary estimates would have been appropriated and expended for Federal public health care programs, including funds that would have been appropriated under the Medicare program under title XVIII of the Social Security Act, under the Medicaid program under title XIX of such Act, and under the Children’s Health Insurance Program under title XXI of such Act.