Sec. 602. Computation of individual and State capitation amounts
818 words·~4 min read·
/bill/113/hr/1200/ih/section-602·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
In establishing the national health security budget under section 601(a) and in computing the national average per capita cost under subsection
(b)for each year, the Board shall establish a method for computing the capitation amount for each eligible individual residing in each State. The capitation amount for an eligible individual in a State classified within a risk group (established under subsection (d)(2)) is the product of— a national average per capita cost for all covered health care services (computed under subsection (b)); the State adjustment factor (established under subsection (c)) for the State; and the risk adjustment factor (established under subsection (d)) for the risk group. For purposes of this title, the term State capitation amount means, for a State for a year, the sum of the capitation amounts computed under paragraph
(1)for all the residents of the State in the year, as estimated by the Board before the beginning of the year involved. The Board may provide for the computation of State capitation amounts based on statistical models that fairly reflect the elements that comprise the State capitation amount described in subparagraph (A). The Bureau of the Census shall assist the Board in determining the number, place of residence, and risk group classification of eligible individuals. For 2014, the national average per capita cost under this paragraph is equal to— the average per capita health care expenditures in the United States in 2012 (as estimated by the Board); increased to 2013 by the Board’s estimate of the actual amount of such per capita expenditures during 2013; and updated to 2014 by the national health security spending growth limit specified in section 601(b)(2) for 2014. For each succeeding year, the national average per capita cost under this subsection is equal to the national average per capita cost computed under this subsection for the previous year increased by the national health security spending growth limit (specified in section 601(b)(2)) for the year involved. Subject to the succeeding paragraphs of this subsection, the Board shall develop for each State a factor to adjust the national average per capita costs to reflect differences between the State and the United States in— average labor and nonlabor costs that are necessary to provide covered health services; any social, environmental, or geographic condition affecting health status or the need for health care services, to the extent such a condition is not taken into account in the establishment of risk groups under subsection (d); the geographic distribution of the State’s population, particularly the proportion of the population residing in medically underserved areas, to the extent such a condition is not taken into account in the establishment of risk groups under subsection (d); and any other factor relating to operating costs required to ensure equitable distribution of funds among the States. With respect to the portion of the national health security budget allocated to expenditures for health professional education, the Board shall modify the State adjustment factors so as to take into account— differences among States in health professional education programs in operation as of the date of the enactment of this Act; and differences among States in their relative need for expenditures for health professional education, taking into account the health professional education expenditures proposed in State health security budgets under section 603(a). The State adjustment factors, as modified under paragraph (2), shall be applied under this subsection in a manner that results in neither an increase nor a decrease in the total amount of the Federal contributions to all State health security programs under subsection
(b)as a result of the application of such factors. In applying State adjustment factors under this subsection during the 5-year period beginning with 2014, the Board shall phase-in, over such period, the use of factors described in paragraph
(1)in a manner so that the adjustment factor for a State is based on a blend of such factors and a factor that reflects the relative actual average per capita costs of health services of the different States as of the time of enactment of this Act. In establishing the national health security budget before the beginning of each year, the Board shall provide for appropriate adjustments in the State adjustment factors under this subsection. The Board shall develop an adjustment factor to the national average per capita costs computed under subsection
(b)for individuals classified in each risk group (as designated under paragraph (2)) to reflect the difference between the average national average per capita costs and the national average per capita cost for individuals classified in the risk group. The Board shall designate a series of risk groups, determined by age, health indicators, and other factors that represent distinct patterns of health care services utilization and costs. In establishing the national health security budget before the beginning of each year, the Board shall provide for appropriate adjustments in the risk adjustment factors under this subsection.