Sec. 303. Qualifications for comprehensive health service organizations
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/bill/113/hr/1200/ih/section-303·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
For purposes of this Act, a comprehensive health service organization (in this section referred to as a CHSO ) is a public or private organization which, in return for a capitated payment amount, undertakes to furnish, arrange for the provision of, or provide payment with respect to— a full range of health services (as identified by the Board), including at least hospital services and physicians services; and out-of-area coverage in the case of urgently needed services; to an identified population which is living in or near a specified service area and which enrolls voluntarily in the organization.
All eligible persons living in or near the specified service area of a CHSO are eligible to enroll in the organization; except that the number of enrollees may be limited to avoid overtaxing the resources of the organization. Subject to paragraph (3), the minimum period of enrollment with a CHSO shall be 1 year, unless the enrolled individual becomes ineligible to enroll with the organization. Each CHSO shall permit an enrolled individual to disenroll from the organization for cause at any time.
Each CHSO, to the maximum extent feasible, shall make all health services readily and promptly accessible to enrollees who live in the specified service area. Each CHSO shall furnish services in such manner as to provide continuity of care and (when services are furnished by different providers) shall provide ready referral of patients to such services and at such times as may be medically appropriate. In the case of a CHSO that is a private organization— At least one-third of the members of the CHSO’s board of directors shall be consumer members with no direct or indirect, personal or family financial relationship to the organization.
The CHSO’s board of directors shall include at least one member who represents health care providers. Each CHSO shall have in effect a patient grievance program and shall conduct regularly surveys of the satisfaction of members with services provided by or through the organization. Each CHSO shall provide that a committee or committees of health care practitioners associated with the organization will promulgate medical standards, oversee the professional aspects of the delivery of care, perform the functions of a pharmacy and drug therapeutics committee, and monitor and review the quality of all health services (including drugs, education, and preventive services).
The Board shall determine appropriate measures to assess the quality of care furnished by the CHSO, such as measures of— clinical processes and outcomes; patient and, where practicable, caregiver experience of care; and utilization (such as rates of hospital admissions for ambulatory care sensitive conditions). The CHSO shall— define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies; and demonstrate to the Board that the CHSO meets patient-centeredness criteria specified by the Board, such as the use of patient and caregiver assessments or the use of individualized care plans.
A CHSO shall submit data in a form and manner specified by the Board on measures the Board determines necessary in order to evaluate the quality of care furnished by the CHSO. Such data may include care transitions across health care settings, including hospital discharge planning and post-hospital discharge follow-up by CHSO professionals, as the Board determines appropriate. The Board shall establish quality performance standards to assess the quality of care furnished by CHSOs and shall seek to improve the quality of care furnished by CHSOs over time by specifying higher standards, new measures, or both for purposes of assessing such quality of care.
Premiums or other charges by a CHSO for any services not paid for under this Act shall be reasonable. Each CHSO shall— comply with the requirements of section 1876(i)(8) of the Social Security Act (relating to prohibiting physician incentive plans that provide specific inducements to reduce or limit medically necessary services); and make available to its membership utilization information and data regarding financial performance, including bonus or incentive payment arrangements to practitioners.
The organization shall arrange to reimburse for hospital services and other facility-based services (as identified by the Board) for services provided to members of the organization in accordance with the global operating budget of the hospital or facility approved under section 611. Each CHSO shall provide for the marketing of its services (including dissemination of marketing materials) to potential enrollees in a manner that is designed to enroll individuals representative of the different population groups and geographic areas included within its service area and meets such requirements as the Board or a State health security program may specify.
Each CHSO shall meet— such requirements relating to minimum enrollment; such requirements relating to financial solvency; such requirements relating to quality and availability of care; and such other requirements, as the Board or a State health security program may specify. A CHSO may furnish emergency services to persons who are not enrolled in the organization. Payment for such services, if they are covered services to eligible persons, shall be made to the organization unless the organization requests that it be made to the individual provider who furnished the services.