Title I, SEC. 1222. GENERAL REQUIREMENTS FOR SINGLE-PAYER SYSTEMS. Each single-payer system shall meet the following requirements: (1) Establishment by state. The system is established under State law, and State law provides for mechanisms to enforce the requirements of the plan. (2) Operation by state. The system is operated by the State or a designated agency of the State. (3) Enrollment of eligible individuals. (A) Mandatory enrollment of all regional alliance individuals. The system provides for the enrollment of all eligible individuals residing in the State (or, in the case of an alliance-specific single-payer system, in the alliance area) for whom the applicable health plan would otherwise be a regional alliance health plan. (B) Optional enrollment of medicare-eligible individuals. At the option of the State, the system may provide for the enrollment of medicare-individuals residing in the State (or, in the case of an alliance-specific single-payer system, in the alliance area) if the Secretary of Health and Human Services has approved an application submitted by the State under section 1893 of the Social Security Act (as added by section 4001(a)) for the integration of medicare beneficiaries into plans of the State. Nothing in this subparagraph shall be construed as requiring that a State have a single-payer system in order to provide for such integration. (C) Optional enrollment of corporate alliance individuals in statewide plans. At the option of the State, a Statewide single-payer system may provide for the enrollment of individuals residing in the State who are otherwise eligible to enroll in a corporate alliance health plan under section 1311. (D) Options included in State system document. A State may not exercise any of the options described in subparagraphs (A) or (B) for a year unless the State included a description of the option in the submission of its system document to the Board for the year under section 1200(b). (E) Exclusion of certain individuals. A single-payer system may not require the enrollment of electing veterans, active duty military personnel, and electing Indians (as defined in 1012(d)). (4) Direct payment to providers. (A) In general. With respect to providers who furnish items and services included in the comprehensive benefit package to individuals enrolled in the system, the State shall make payments directly to such providers and assume (subject to subparagraph (B)) all financial risk associated with making such payments. (B) Capitated payments permitted. Nothing in subparagraph (A) shall be construed to prohibit providers furnishing items and services under the system from receiving payments from the plan on a capitated, at-risk basis based on prospectively determined rates. (5) Provision of comprehensive benefit package. (A) In general. The system shall provide for coverage of the comprehensive benefit package, including the cost sharing provided under the package (subject to subparagraph (B)), to all individuals enrolled in the system. (B) Imposition of reduced cost sharing. The system may decrease the cost sharing otherwise provided in the comprehensive benefit package with respect to any class of individuals enrolled in the system or any class of services included in the package, so long as the system does not increase the cost sharing otherwise imposed with respect to any other class of individuals or services. (6) Cost containment. The system shall provide for mechanisms to ensure, in a manner satisfactory to the Board, that (A) per capita expenditures for items and services in the comprehensive benefit package under the system for a year (beginning with the first year) do not exceed an amount equivalent to the regional alliance per capita premium target that is determined under section 6003 (based on the State being a single regional alliance) for the year; (B) the per capita expenditures described in subparagraph (A) are computed and effectively monitored; and (C) automatic, mandatory, nondiscretionary reductions in payments to health care providers will be imposed to the extent required to assure that such per capita expenditures do not exceed in the applicable target referred to in subparagraph (A). (7) Requirements generally applicable to health plans. The system shall meet the requirements applicable to a health plan under section 1400(a), except that (A) the system does not have the authority provided to health plans under section 1402(a)(2) (relating to permissible limitations on the enrollment of eligible individuals on the basis of limits on the plan's capacity); (B) the system is not required to meet the requirements of section 1404(a) (relating to restrictions on the marketing of plan materials); and (C) the system is not required to meet the requirements of section 1408 (relating to plan solvency).