STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
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STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
(Senate - June 10, 1997)
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S5444-S5464]
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
By Mr. MOYNIHAN (for himself and Mr. Sarbames):
S. 863. A bill to authorize the Government of India to establish a
memorial to honor Mahatma Gandhi in the District of Columbia; to the
Committee on Energy and Natural Resources.
Legislation to Establish Mahatma Gandhi Memorial
Mr. MOYNIHAN. Mr. President, I rise to introduce a bill to authorize
the placement of a statue of Mohandas Karamchand Gandhi --Mahatma
Gandhi--on Federal land across the street from the Indian embassy in
Washington DC. The Government of India has offered a statue of Gandhi
as a gift to the United States. In order to place it on Federal land,
an act of Congress is required. This bill will fulfill just that
purpose, and I thank the Senator from Florida [Mr. Mack] and the
Senator from Maryland, [Mr. Sarbanes] for joining me in this endeavor.
India is currently celebrating the 50th anniversary of its
independence. Authorizing the placement of a statue of Mahatma Gandhi,
often called the father of the Indian nation, would serve as a fitting
tribute to Indian democracy which has survived--in fact, thrived--
despite enormous challenges, and a symbol of the growing strength of
the bonds between our two countries.
It is particularly appropriate that a statue of Mahatma Gandhi be
selected for this purpose. The effects of his non-
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violent actions and the philosophy which guided them were not limited
to his country, nor his time. His influence in the United States was
most notably felt in the civil rights movement, but has also infused
all levels of our society.
If I may invade ever so slightly the privacy of the President's
luncheon table, in May 1994, Mr. Clinton had as his guest the
distinguished Prime Minister of India, Mr. P.V. Narasimha Rao, who in
his youth was a follower of Mahatma Gandhi. In a graceful passage,
Prime Minister Rao related how it came to pass that Mahatma Gandhi,
caught up in the struggle for fair treatment to the Indian community in
South Africa, and in consequence in jail, read Thoreau's essay on
``Civil Disobedience'' which confirmed his view that an honest man is
duty-bound to violate unjust laws. He took this view home with him, and
in the end the British raj gave way to an independent Republic of
India. Then Martin Luther King, Jr., repatriated the idea and so began
the great civil rights movement of this century.
Dr. Martin Luther King, Jr., has written of the singular influence
Gandhi's message of nonviolent resistance had on him when he first
learned of it while studying at Crozier Theological Seminary in
Philadelphia. He would later describe that influence in his first book,
``Stride Toward Freedom'':
As I read I became deeply fascinated by [Gandhi's]
philosophy of non-violent resistance . . . as I delved deeper
into the philosophy of Gandhi, my skepticism concerning the
power of love gradually diminished, and I came to see its
potency in the area of social reform . . . prior to reading
Gandhi, I had concluded that the love ethics of Jesus were
only effective in individual relationships . . . but after
reading Gandhi, I saw how utterly mistaken I was.
. . . It was in this Gandhian emphasis on love and non-
violence that I discovered the method for social reform that
I had been seeking for so many months . . . I came to feel
that this was the only morally and practically sound method
open to oppressed people in their struggle for freedom . . .
this principle became the guiding light of our movement.
Christ furnished the spirit and motivation and Gandhi
furnished the method.
Martin Luther King, Jr., believed that Gandhi's philosophy of
nonviolent resistance was the guiding light of the American civil
rights movement. As Dr. King wrote, ``Gandhi furnished the message.'' A
statue of Gandhi, given as a gift from the Government of India, on a
small plot of Federal land along Massachusetts Avenue, in front of the
Indian Embassy, will stand not only as a tribute to the shared values
of the two largest democracies in the world but will also pay tribute
to the lasting influence of Gandhian thought on the United States. An
influence that is so pervasive that when the President and the Prime
Minister of India meet at the White House for lunch, a half-century
after Gandhi's death, it is no surprise that he should be a topic of
conversation.
______
By Mr. CHAFEE (for himself, Mr. Breaux, Mr. Kerrey, and Mr.
Conrad):
S. 864. A bill to amend title XIX of the Social Security Act to
improve the provision of managed care under the Medicaid Program; to
the Committee on Finance.
The Medicaid Managed Care Act of 1997
Mr. CHAFEE. Mr. President, I am pleased today to introduce The
Medicaid Managed Care Act of 1997. This legislation meets two very
important objectives in the Medicaid Program. First, it gives States
the additional flexibility they need to administer the Medicaid Program
by allowing them to enroll Medicaid beneficiaries into managed care
Programs. Second, the bill sets Federal standards for managed care to
ensure that Medicaid patients receive the same quality of care as those
patients who are enrolled in private managed care plans.
Under our legislation, States could require Medicaid patients to
enroll in managed care plans without going through the lengthy and
cumbersome process of applying to the Secretary of Health and Human
Services for a waiver of current Medicaid regulations. In exchange for
this important flexibility, States will have to meet a set of minimum
Federal standards to ensure that Medicaid patients continue to receive
quality care.
For example, States would be required to offer patients a choice of
at least two health plans. Plans would be required to meet certain
standards of access to care, quality, and solvency. These standards are
especially important given recent problems in States that have set up
Medicaid managed care programs under the waiver process. In some
instances, plans have failed to contract with enough providers to serve
the Medicaid population. Some have been permitted to operate under
standards that are lower than commercial insurers are required to meet,
and others have used fraudulent marketing practices to entice Medicaid
patients to sign up with their plans. These actions have resulted in
patients being denied medically necessary services, and have resulted
in States and the Federal Government paying for care that was never
given.
Considering these abuses, why should we allow Medicaid managed care
at all? Because managed care, if implemented correctly, can vastly
improve the quality of health care provided to low-income families. In
today's fee-for-service program, patients face myriad problems. Some
are forced to get care in hospital emergency rooms because they cannot
find a private physician willing or able to accept Medicaid's low
payment rates. Those who do have access to providers often must wait
for hours in clinics which are overcrowded and understaffed. And,
sadly, they often do not have access to primary and preventive care
services which would have prevented them from becoming ill to begin
with.
Medicaid managed care, if done well, provides regular prenatal care
to assure that children are born healthy. These plans provide coverage
for check-ups and immunizations to prevent serious illnesses. And they
give patients a medical home--a provider they know they can go to if
they are sick, or a number to call if they have questions.
Medicaid managed care also has the potential of benefiting our
overall health care system by providing access to primary care
providers rather than forcing patients to make costly and unnecessary
visits to hospital emergency rooms. It gives providers the opportunity
to catch and treat, or prevent, costly health problems.
Mr. President, we have worked very hard to ensure that this
legislation strikes an appropriate balance between the needs of
Medicaid beneficiaries and the managed care companies. I want to thank
Senators Breaux and Kerrey who helped craft this legislation and are
original cosponsors. I also want to thank the many advocacy
organizations for their input and support. And I also want to thank
some of the managed care organizations who worked with us. I am
especially pleased that some of these organizations, such as the HMO
Group which is an alliance of health maintenance organizations have
endorsed this legislation. Their support is critical to the success of
Medicaid managed care.
I ask unanimous consent that the text of the legislation be included
in the Record.
There being no objection, the bill was ordered to be printed in the
Record, as follows:
S. 864
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS; AMENDMENTS TO THE
SOCIAL SECURITY ACT.
(a) Short Title.--This Act may be cited as the ``Medicaid
Managed Care Improvement Act of 1997''.
(b) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents; amendments to the Social
Security Act.
Sec. 2. Improvements in medicaid managed care program.
``Part B--Provisions Relating to Managed Care
``Sec. 1941. Beneficiary choice; enrollment.
``Sec. 1942. Beneficiary access to services generally.
``Sec. 1943. Beneficiary access to emergency care.
``Sec. 1944. Other beneficiary protections.
``Sec. 1945. Assuring quality care.
``Sec. 1946. Protections for providers.
``Sec. 1947. Assuring adequacy of payments to medicaid managed care
organizations and entities.
``Sec. 1948. Fraud and abuse.
``Sec. 1949. Sanctions for noncompliance by managed care entities.
``Sec. 1950. Definitions; miscellaneous provisions.''
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Sec. 3. Studies and reports.
Sec. 4. Conforming amendments.
Sec. 5. Effective date; status of waivers.
(c) Amendments to Social Security Act.--Except as otherwise
specifically provided, whenever in this Act an amendment is
expressed in terms of an amendment to or repeal of a section
or other provision, the reference shall be considered to be
made to that section or other provision of the Social
Security Act.
SEC. 2. IMPROVEMENTS IN MEDICAID MANAGED CARE PROGRAM.
Title XIX is amended--
(1) by inserting after the title heading the following:
``Part A--General Provisions''; and
(2) by adding at the end the following new part:
``Part B--Provisions Relating to Managed Care
``SEC. 1941. BENEFICIARY CHOICE; ENROLLMENT.
``(a) State Options for Enrollment of Beneficiaries in
Managed Care Arrangements.--
``(1) In general.--Subject to the succeeding provisions of
this part and notwithstanding paragraphs (1), (10)(B), and
(23)(A) of section 1902(a), a State may require an individual
who is eligible for medical assistance under the State plan
under this title and who is not a special needs individual
(as defined in subsection (e)) to enroll with a managed care
entity (as defined in section 1950(a)(1)) as a condition of
receiving such assistance (and, with respect to assistance
furnished by or under arrangements with such entity, to
receive such assistance through the entity), if the following
provisions are met:
``(A) Entity meets requirements.--The entity meets the
applicable requirements of this part.
``(B) Contract with state.--The entity enters into a
contract with the State to provide services for the benefit
of individuals eligible for benefits under this title under
which prepaid payments to such entity are made on an
actuarially sound basis. Such contract shall specify benefits
the provision (or arrangement) for which the entity is
responsible.
``(C) Choice of coverage.--
``(i) In general.--The State permits an individual to
choose a managed care entity from managed care organizations
and primary care case providers who meet the requirements of
this part but not less than from--
``(I) 2 medicaid managed care organizations,
``(II) a medicaid managed care organization and a primary
care case management provider, or
``(III) a primary care case management provider as long as
an individual may choose between 2 primary care case
managers.
``(ii) State option.--At the option of the State, a State
shall be considered to meet the requirements of clause (i) in
the case of an individual residing in a rural area, if the
State--
``(I) requires the individual to enroll with a medicaid
managed care organization or primary care case management
provider if such organization or entity permits the
individual to receive such assistance through not less than 2
physicians or case managers (to the extent that at least 2
physicians or case managers are available to provide such
assistance in the area), and
``(II) permits the individual to obtain such assistance
from any other provider in appropriate circumstances (as
established by the State under regulations of the Secretary).
``(D) Changes in enrollment.--The State provides the
individual with the opportunity to change enrollment among
managed care entities once annually and notifies the
individual of such opportunity not later than 60 days prior
to the first date on which the individual may change
enrollment, permits individuals to change their enrollment
for cause at any time and without cause at least every 12
months, and allows individuals to disenroll without cause
within 90 days of notification of enrollment.
``(E) Enrollment priorities.--The State establishes a
method for establishing enrollment priorities in the case of
a managed care entity that does not have sufficient capacity
to enroll all such individuals seeking enrollment under which
individuals already enrolled with the entity are given
priority in continuing enrollment with the entity.
``(F) Default enrollment process.--The State establishes a
default enrollment process which meets the requirements
described in paragraph (2) and under which any such
individual who does not enroll with a managed care entity
during the enrollment period specified by the State shall be
enrolled by the State with such an entity in accordance with
such process.
``(G) Sanctions.--The State establishes the sanctions
provided for in section 1949.
``(2) Default enrollment process requirements.--The default
enrollment process established by a State under paragraph
(1)(F)--
``(A) shall provide that the State may not enroll
individuals with a managed care entity which is not in
compliance with the applicable requirements of this part;
``(B) shall provide (consistent with subparagraph (A)) for
enrollment of such an individual with a medicaid managed care
organization--
``(i) first, that maintains existing provider-individual
relationships or that has entered into contracts with
providers (such as Federally qualified health centers, rural
health clinics, hospitals that qualify for disproportionate
share hospital payments under section 1886(d)(5)(F), and
hospitals described in section 1886(d)(1)(B)(iii)) that have
traditionally served beneficiaries under this title, and
``(ii) lastly, if there is no provider described in clause
(i), in a manner that provides for an equitable distribution
of individuals among all qualified managed care entities
available to enroll individuals through such default
enrollment process, consistent with the enrollment capacities
of such entities;
``(C) shall permit and assist an individual enrolled with
an entity under such process to change such enrollment to
another managed care entity during a period (of at least 90
days) after the effective date of the enrollment; and
``(D) may provide for consideration of factors such as
quality, geographic proximity, continuity of providers, and
capacity of the plan when conducting such process.
``(b) Reenrollment of Individuals Who Regain Eligibility.--
``(1) In general.--If an individual eligible for medical
assistance under a State plan under this title and enrolled
with a managed care entity with a contract under subsection
(a)(1)(B) ceases to be eligible for such assistance for a
period of not greater than 2 months, the State may provide
for the automatic reenrollment of the individual with the
entity as of the first day of the month in which the
individual is again eligible for such assistance, and may
consider factors such as quality, geographic proximity,
continuity of providers, and capacity of the plan when
conducting such reenrollment.
``(2) Conditions.--Paragraph (1) shall only apply if--
``(A) the month for which the individual is to be
reenrolled occurs during the enrollment period covered by the
individual's original enrollment with the managed care
entity;
``(B) the managed care entity continues to have a contract
with the State agency under subsection (a)(1)(B) as of the
first day of such month; and
``(C) the managed care entity complies with the applicable
requirements of this part.
``(3) Notice of reenrollment.--The State shall provide
timely notice to a managed care entity of any reenrollment of
an individual under this subsection.
``(c) State Option of Minimum Enrollment Period.--
``(1) In general.--In the case of an individual who is
enrolled with a managed care entity under this part and who
would (but for this subsection) lose eligibility for benefits
under this title before the end of the minimum enrollment
period (defined in paragraph (2)), the State plan under this
title may provide, notwithstanding any other provision of
this title, that the individual shall be deemed to continue
to be eligible for such benefits until the end of such
minimum period, but, except for benefits furnished under
section 1902(a)(23)(B), only with respect to such benefits
provided to the individual as an enrollee of such entity.
``(2) Minimum enrollment period defined.--For purposes of
paragraph (1), the term `minimum enrollment period' means,
with respect to an individual's enrollment with an entity
under a State plan, a period, established by the State, of
not more than 6 months beginning on the date the individual's
enrollment with the entity becomes effective, except that a
State may extend such period for up to a total of 12 months
in the case of an individual's enrollment with a managed care
entity (as defined in section 1950(a)(1)) so long as such
extension is done uniformly for all individuals enrolled with
all such entities.
``(d) Other Enrollment-Related Provisions.--
``(1) Nondiscrimination.--A managed care entity may not
discriminate on the basis of health status or anticipated
need for services in the enrollment, reenrollment, or
disenrollment of individuals eligible to receive medical
assistance under a State plan under this title or by
discouraging enrollment (except as permitted by this section)
by eligible individuals.
``(2) Termination of enrollment.--
``(A) In general.--The State, enrollment broker, and
managed care entity (if any) shall permit an individual
eligible for medical assistance under the State plan under
this title who is enrolled with the entity to terminate such
enrollment for cause at any time, and without cause during
the 90-day period beginning on the date the individual
receives notice of enrollment and at least every 12 months
thereafter, and shall notify each such individual of the
opportunity to terminate enrollment under these conditions.
``(B) Fraudulent inducement or coercion as grounds for
cause.--For purposes of subparagraph (A), an individual
terminating enrollment with a managed care entity on the
grounds that the enrollment was based on fraudulent
inducement or was obtained through coercion or pursuant to
the imposition against the managed care entity of the
sanction described in section 1949(b)(3) shall be considered
to terminate such enrollment for cause.
``(C) Notice of termination.--
``(i) Notice to state.--
``(I) By individuals.--Each individual terminating
enrollment with a managed care entity under subparagraph (A)
shall do so by
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providing notice of the termination to an office of the State
agency administering the State plan under this title, the
State or local welfare agency, or an office of a managed care
entity.
``(II) By organizations.--Any managed care entity which
receives notice of an individual's termination of enrollment
with such entity through receipt of such notice at an office
of a managed care entity shall provide timely notice of the
termination to the State agency administering the State plan
under this title.
``(ii) Notice to plan.--The State agency administering the
State plan under this title or the State or local welfare
agency which receives notice of an individual's termination
of enrollment with a managed care entity under clause (i)
shall provide timely notice of the termination to such
entity.
``(3) Provision of information.--
``(A) In general.--Each State, enrollment broker, or
managed care organization shall provide all enrollment
notices and informational and instructional materials in a
manner and form which may be easily understood by enrollees
of the entity who are eligible for medical assistance under
the State plan under this title, including enrollees and
potential enrollees who are blind, deaf, disabled, or cannot
read or understand the English language.
``(B) Information to health care providers, enrollees, and
potential enrollees.--Each medicaid managed care organization
shall--
``(i) upon request, make the information described in
section 1945(e)(1)(A)available to enrollees and potential
enrollees in the organization's service area; and
``(ii) provide to enrollees and potential enrollees
information regarding all items and services that are
available to enrollees under the contract between the State
and the organization that are covered either directly or
through a method of referral and prior authorization.
``(e) Special Needs Individuals Described.--In this part,
the term `special needs individual' means any of the
following individuals:
``(1) Special needs child.--An individual who is under 19
years of age who--
``(A) is eligible for supplemental security income under
title XVI;
``(B) is described under section 501(a)(1)(D);
``(C) is a child described in section 1902(e)(3);
``(D) is receiving services under a program under part B or
part E of title IV; or
``(E) is not described in any preceding subparagraph but is
otherwise considered a child with special health care needs
who is adopted, in foster care, or otherwise in an out-of-
home placement.
``(2) Homeless individuals.--An individual who is homeless
(without regard to whether the individual is a member of a
family), including--
``(A) an individual whose primary residence during the
night is a supervised public or private facility that
provides temporary living accommodations; or
``(B) an individual who is a resident in transitional
housing.
``(3) Migrant agricultural workers.--A migratory
agricultural worker or a seasonal agricultural worker (as
such terms are defined in section 330(g)(3) of the Public
Health Service Act), or the spouse or dependent of such a
worker.
``(4) Indians.--An Indian (as defined in section 4(c) of
the Indian Health Care Improvement Act (25 U.S.C. 1603(c))).
``(5) Medicare beneficiaries.--A qualified medicare
beneficiary (as defined in section 1905(p)(1)) or an
individual otherwise eligible for benefits under title XVIII.
``(6) Disabled individuals.--Individuals who are disabled
(as determined under section 1614(a)(3)).
``(7) Persons with aids or hiv infection.--An individual
with acquired immune deficiency syndrome (AIDS) or who has
been determined to be infected with the HIV virus.
``SEC. 1942. BENEFICIARY ACCESS TO SERVICES GENERALLY.
``(a) Access to Services.--
``(1) In general.--Each managed care entity shall provide
or arrange for the provision of all medically necessary
medical assistance under this title which is specified in the
contract entered into between such entity and the State under
section 1941(a)(1)(B) for enrollees who are eligible for
medical assistance under the State plan under this title.
``(2) Primary-care-provider-to-enrollee ratio and maximum
travel time.--Each such entity shall assure adequate access
to primary care services by meeting standards, established by
the Secretary, relating to the maximum ratio of enrollees
under this title to full-time-equivalent primary care
providers available to serve such enrollees and to maximum
travel time for such enrollees to access such providers. The
Secretary may permit such a maximum ratio to vary depending
on the area and population served. Such standards shall be
based on standards commonly applied in the commercial market,
commonly used in accreditation of managed care organizations,
and standards used in the approval of waiver applications
under section 1115, and shall be consistent with the
requirements under section 1876(c)(4)(A).
``(b) Obstetrical and Gynecological Care.--
``(1) In general.--A managed care entity may not require
prior authorization by the individual's primary care provider
or otherwise restrict the individual's access to
gynecological and obstetrical care provided by a
participating provider who specializes in obstetrics and
gynecology to the extent such care is otherwise covered, and
may treat the ordering of other obstetrical and gynecological
care by such a participating provider as the prior
authorization of the primary care provider with respect to
such care under the coverage.
``(2) Construction.--Nothing in paragraph (1)(B)(ii) shall
waive any requirements of coverage relating to medical
necessity or appropriateness with respect to coverage of
gynecological care so ordered.
``(c) Specialty Care.--
``(1) Referral to specialty care for enrollees requiring
treatment by specialists.--
``(A) In general.--In the case of an enrollee under a
managed care entity and who has a condition or disease of
sufficient seriousness and complexity to require treatment by
a specialist, the entity shall make or provide for a referral
to a specialist who is available and accessible to provide
the treatment for such condition or disease.
``(B) Specialist defined.--For purposes of this subsection,
the term `specialist' means, with respect to a condition, a
health care practitioner, facility, or center (such as a
center of excellence) that has adequate expertise through
appropriate training and experience (including, in the case
of a child, an appropriate pediatric specialist) to provide
high quality care in treating the condition.
``(C) Care under referral.--Care provided pursuant to such
referral under subparagraph (A) shall be--
``(i) pursuant to a treatment plan (if any) developed by
the specialist and approved by the entity, in consultation
with the designated primary care provider or specialist and
the enrollee (or the enrollee's designee), and
``(ii) in accordance with applicable quality assurance and
utilization review standards of the entity.
Nothing in this subsection shall be construed as preventing
such a treatment plan for an enrollee from requiring a
specialist to provide the primary care provider with regular
updates on the specialty care provided, as well as all
necessary medical information.
``(D) Referrals to participating providers.--An entity is
not required under subparagraph (A) to provide for a referral
to a specialist that is not a participating provider, unless
the entity does not have an appropriate specialist that is
available and accessible to treat the enrollee's condition
and that is a participating provider with respect to such
treatment.
``(E) Treatment of nonparticipating providers.--If an
entity refers an enrollee to a nonparticipating specialist,
services provided pursuant to the approved treatment plan
shall be provided at no additional cost to the enrollee
beyond what the enrollee would otherwise pay for services
received by such a specialist that is a participating
provider.
``(2) Specialists as primary care providers.--
``(A) In general.--A managed care entity shall have a
procedure by which a new enrollee upon enrollment, or an
enrollee upon diagnosis, with an ongoing special condition
(as defined in subparagraph (C)) may receive a referral to a
specialist for such condition who shall be responsible for
and capable of providing and coordinating the enrollee's
primary and specialty care. If such an enrollee's care would
most appropriately be coordinated by such a specialist, the
entity shall refer the enrollee to such specialist.
``(B) Treatment as primary care provider.--Such specialist
shall be permitted to treat the enrollee without a referral
from the enrollee's primary care provider and may authorize
such referrals, procedures, tests, and other medical services
as the enrollee's primary care provider would otherwise be
permitted to provide or authorize, subject to the terms of
the treatment plan (referred to in paragraph (1)(C)(i)).
``(C) Ongoing special condition defined.--In this
paragraph, the term `special condition' means a physical and
mental condition or disease that--
``(i) is life-threatening, degenerative, or disabling, and
``(ii) requires specialized medical care over a prolonged
period of time.
``(D) Terms of referral.--The provisions of subparagraphs
(C) through (E) of paragraph (1) shall apply with respect to
referrals under subparagraph (A) of this paragraph in the
same manner as they apply to referrals under paragraph
(1)(A).
``(3) Standing referrals.--
``(A) In general.--A managed care entity shall have a
procedure by which an enrollee who has a condition that
requires ongoing care from a specialist may receive a
standing referral to such specialist for treatment of such
condition. If the issuer, or the primary care provider in
consultation with the medical director of the entity and the
specialist (if any), determines that such a standing referral
is appropriate, the entity shall make such a referral to such
a specialist.
``(B) Terms of referral.--The provisions of subparagraphs
(C) through (E) of paragraph (1) shall apply with respect to
referrals under subparagraph (A) of this paragraph in the
same manner as they apply to referrals under paragraph
(1)(A).
``(d) Timely Delivery of Services.--Each managed care
entity shall respond to requests from enrollees for the
delivery of medical assistance in a manner which--
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``(1) makes such assistance--
``(A) available and accessible to each such individual,
within the area served by the entity, with reasonable
promptness and in a manner which assures continuity; and
``(B) when medically necessary, available and accessible 24
hours a day and 7 days a week; and
``(2) with respect to assistance provided to such an
individual other than through the entity, or without prior
authorization, in the case of a primary care case management
provider, provides for reimbursement to the individual (if
applicable under the contract between the State and the
entity) if--
``(A) the services were medically necessary and immediately
required because of an unforeseen illness, injury, or
condition and meet the requirements of section 1943; and
``(B) it was not reasonable given the circumstances to
obtain the services through the entity, or, in the case of a
primary care case management provider, with prior
authorization.
``(e) Internal Grievance Procedure.--Each medicaid managed
care organization shall establish an internal grievance
procedure under which an enrollee who is eligible for medical
assistance under the State plan under this title, or a
provider on behalf of such an enrollee, may challenge the
denial of coverage of or payment for such assistance.
``(f) Information on Benefit Carve Outs.--Each managed care
entity shall inform each enrollee, in a written and prominent
manner, of any benefits to which the enrollee may be entitled
to medical assistance under this title but which are not made
available to the enrollee through the entity. Such
information shall include information on where and how such
enrollees may access benefits not made available to the
enrollee through the entity.
``(g) Due Process Requirements for Managed Care Entities.--
``(1) Denial of or unreasonable delay in determining
coverage as grounds for hearing.--If a managed care entity
(or entity acting an agreement with a managed care entity)--
``(A) denies coverage of or payment for medical assistance
with respect to an enrollee who is eligible for such
assistance under the State plan under this title; or
``(B) fails to make any eligibility or coverage
determination sought by an enrollee or, in the case of a
medicaid managed care organization, by a participating health
care provider or enrollee, in a timely manner, depending upon
the urgency of the situation,
the enrollee or the health care provider furnishing such
assistance to the enrollee (as applicable) may obtain a fair
hearing before, and shall be provided a timely decision by,
the State agency administering the State plan under this
title in accordance with section 1902(a)(3). Such decisions
shall be rendered as soon as possible in accordance with the
medical exigencies of the cases, and in no event later than
72 hours in the case of hearings on decisions regarding
urgent care and 5 days in the case of all other hearings.
``(2) Completion of internal grievance procedure.--Nothing
in this subsection shall require completion of an internal
grievance procedure if the procedure does not provide for
timely review of health needs considered by the enrollee's
health care provider to be of an urgent nature or is not
otherwise consistent with the requirements for such
procedures under section 1876(c).
``(h) Demonstration of Adequate Capacity and Services.--
``(1) In general.--Subject to paragraph (3), each medicaid
managed care organization shall provide the State and the
Secretary with adequate assurances (as determined by the
Secretary) that the organization, with respect to a service
area--
``(A) has the capacity to serve the expected enrollment in
such service area;
``(B) offers an appropriate range of services for the
population expected to be enrolled in such service area,
including transportation services and translation services
consisting of the principal languages spoken in the service
area;
``(C) maintains a sufficient number, mix, and geographic
distribution of providers of services included in the
contract with the State to ensure that services are available
to individuals receiving medical assistance and enrolled in
the organization to the same extent that such services are
available to individuals enrolled in the organization who are
not recipients of medical assistance under the State plan
under this title;
``(D) maintains extended hours of operation with respect to
primary care services that are beyond those maintained during
a normal business day;
``(E) provides preventive and primary care services in
locations that are readily accessible to members of the
community;
``(F) provides information concerning educational, social,
health, and nutritional services offered by other programs
for which enrollees may be eligible; and
``(G) complies with such other requirements relating to
access to care as the Secretary or the State may impose.
``(2) Proof of adequate primary care capacity and
services.--Subject to paragraph (3), a medicaid managed care
organization that contracts with a reasonable number of
primary care providers (as determined by the Secretary) and
whose primary care membership includes a reasonable number
(as so determined) of the following providers will be deemed
to have satisfied the requirements of paragraph (1):
``(A) Rural health clinics, as defined in section
1905(l)(1).
``(B) Federally-qualified health centers, as defined in
section 1905(l)(2)(B).
``(C) Clinics which are eligible to receive payment for
services provided under title X of the Public Health Service
Act.
``(3) Sufficient providers of specialized services.--
Notwithstanding paragraphs (1) and (2), a medicaid managed
care organization may not be considered to have satisfied the
requirements of paragraph (1) if the organization does not
have a sufficient number (as determined by the Secretary) of
providers of specialized services, including perinatal and
pediatric specialty care, to ensure that such services are
available and accessible.
``(i) Compliance With Certain Maternity and Mental Health
Requirements.--Each medicaid managed care organization shall
comply with the requirements of subpart 2 of part A of title
XXVII of the Public Health Service Act insofar as such
requirements apply with respect to a health insurance issuer
that offers group health insurance coverage.
``(j) Treatment of Children With Special Health Care
Needs.--
``(1) In general.--In the case of an enrollee of a managed
care entity who is a child described in section 1941(e)(1) or
who has special health care needs (as defined in paragraph
(3))--
``(A) if any medical assistance specified in the contract
with the State is identified in a treatment plan prepared for
the enrollee by a program described in subsection (c)(1) or
paragraph (3), the managed care entity shall provide (or
arrange to be provided) such assistance in accordance with
the treatment plan either--
``(i) by referring the enrollee to a pediatric health care
provider who is trained and experienced in the provision of
such assistance and who has a contract with the managed care
entity to provide such assistance; or
``(ii) if appropriate services are not available through
the managed care entity, permitting such enrollee to seek
appropriate specialty services from pediatric health care
providers outside of or apart from the managed care entity;
and
``(B) the managed care entity shall require each health
care provider with whom the managed care entity has entered
into an agreement to provide medical assistance to enrollees
to furnish the medical assistance specified in such
enrollee's treatment plan to the extent the health care
provider is able to carry out such treatment plan.
``(2) Prior authorization.--An enrollee referred for
treatment under paragraph (1)(A)(i), or permitted to seek
treatment outside of or apart from the managed care entity
under paragraph (1)(A)(ii) shall be deemed to have obtained
any prior authorization required by the entity.
``(3) Child with special health care needs.--For purposes
of paragraph (1), a child has special health care needs if
the child is receiving services under--
``(A) a program administered under part B or part H of the
Individuals with Disabilities Education Act; or
``(B) any other program for children with special health
care needs identified by the Secretary.
``SEC. 1943. BENEFICIARY ACCESS TO EMERGENCY CARE.
``(a) Prohibition of Certain Restrictions on Coverage of
Emergency Services.--
``(1) In general.--If a managed care entity provides any
benefits under a State plan with respect to emergency
services (as defined in paragraph (2)(B)), the entity shall
cover emergency services furnished to an enrollee--
``(A) without the need for any prior authorization
determination,
``(B) subject to paragraph (3), whether or not the
physician or provider furnishing such services is a
participating physician or provider with respect to such
services, and
``(C) subject to paragraph (3), without regard to any other
term or condition of such coverage (other than an exclusion
of benefits).
``(2) Emergency services; emergency medical condition.--For
purposes of this section--
``(A) Emergency medical condition based on prudent
layperson.--The term `emergency medical condition' means a
medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a
prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of
immediate medical attention to result in--
``(i) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy,
``(ii) serious impairment to bodily functions, or
``(iii) serious dysfunction of any bodily organ or part.
``(B) Emergency services.--The term `emergency services'
means--
``(i) a medical screening examination (as required under
section 1867) that is within the capability of the emergency
department of a hospital, including ancillary services
routinely available to the emergency department, to evaluate
an emergency medical condition (as defined in subparagraph
(A)), and
``(ii) within the capabilities of the staff and facilities
available at the hospital, such further medical examination
and treatment as
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are required under section 1867 to stabilize the patient.
``(C) Trauma and burn centers.--The provisions of clause
(ii) of subparagraph (B) apply to a trauma or burn center, in
a hospital, that--
``(i) is designated by the State, a regional authority of
the State, or by the designee of the State, or
``(ii) is in a State that has not made such designations
and meets medically recognized national standards.
``(3) Application of network restriction permitted in
certain cases.--
``(A) In general.--Except as provided in subparagraph (B),
if a managed care entity in relation to benefits provided
under this title denies, limits, or otherwise differentiates
in benefits or payment for benefits other than emergency
services on the basis that the physician or provider of such
services is a nonparticipating physician or provider, the
entity may deny, limit, or differentiate in coverage or
payment for emergency services on such basis.
``(B) Network restrictions not permitted in certain
exceptional cases.--The denial or limitation of, or
differentiation in, coverage or payment of benefits for
emergency services under subparagraph (A) shall not apply in
the following cases:
``(i) Circumstances beyond control of enrollee.--The
enrollee is unable to go to a participating hospital for such
services due to circumstances beyond the control of the
enrollee (as determined consistent with guidelines and
subparagraph (C)).
``(ii) Likelihood of an adverse health consequence based on
layperson's judgment.--A prudent layperson possessing an
average knowledge of health and medicine could reasonably
believe that, under the circumstances and consistent with
guidelines, the time required to go to a participating
hospital for such services could result in any of the adverse
health consequences described in a clause of subsection
(a)(2)(A).
``(iii) Physician referral.--A participating physician or
other person authorized by the plan refers the enrollee to an
emergency department of a hospital and does not specify an
emergency department of a hospital that is a participating
hospital with respect to such services.
``(C) Application of `beyond control' standards.--For
purposes of applying subparagraph (B)(i), receipt of
emergency services from a nonparticipating hospital shall be
treated under the guidelines as being `due to circumstances
beyond the control of the enrollee' if any of the following
conditions are met:
``(i) Unconscious.--The enrollee was unconscious or in an
otherwise altered mental state at the time of initiation of
the services.
``(ii) Ambulance delivery.--The enrollee was transported by
an ambulance or other emergency vehicle directed by a person
other than the enrollee to the nonparticipating hospital in
which the services were provided.
``(iii) Natural disaster.--A natural disaster or civil
disturbance prevented the enrollee from presenting to a
participating hospital for the provision of such services.
``(iv) No good faith effort to inform of change in
participation during a contract year.--The status of the
hospital changed from a participating hospital to a
nonparticipating hospital with respect to emergency services
during a contract year and the entity failed to make a good
faith effort to notify the enrollee involved of such change.
``(v) Other conditions.--There were other factors (such as
those identified in guidelines) that prevented the enrollee
from controlling selection of the hospital in which the
services were provided.
``(b) Assuring Coordinated Coverage of Maintenance Care and
Post-Stabilization Care.--
``(1) In general.--In the case of an individual who is
enrolled with a managed care entity and who has received
emergency services pursuant to a screening evaluation
conducted (or supervised) by a treating physician at a
hospital that is a nonparticipating provider with respect to
emergency services, if--
``(A) pursuant to such evaluation, the physician identifies
post-stabilization care (as defined in paragraph (3)(B)) that
is required by the enrollee,
``(B) the coverage through the entity under this title
provides benefits with respect to the care so identified and
the coverage requires (but for this subsection) an
affirmative prior authorization determination as a condition
of coverage of such care, and
``(C) the treating physician (or another individual acting
on behalf of such physician) initiates, not later than 30
minutes after the time the treating physician determines that
the condition of the enrollee is stabilized, a good faith
effort to contact a physician or other person authorized by
the entity (by telephone or other means) to obtain an
affirmative prior authorization determination with respect to
the care,
then, without regard to terms and conditions specified in
paragraph (2) the entity shall cover maintenance care (as
defined in paragraph (3)(A)) furnished to the enrollee during
the period specified in paragraph (4) and shall cover post-
stabilization care furnished to the enrollee during the
period beginning under paragraph (5) and ending under
paragraph (6).
``(2) Terms and conditions waived.--The terms and
conditions (of coverage) described in this paragraph that are
waived under paragraph (1) are as follows:
``(A) The need for any prior authorization determination.
``(B) Any limitation on coverage based on whether or not
the physician or provider furnishing the care is a
participating physician or provider with respect to such
care.
``(C) Any other term or condition of the coverage (other
than an exclusion of benefits and other than a requirement
relating to medical necessity for coverage of benefits).
``(3) Maintenance care and post-stabilization care
defined.--In this subsection:
``(A) Maintenance care.--The term `maintenance care' means,
with respect to an individual who is stabilized after
provision of emergency services, medically necessary items
and services (other than emergency services) that are
required by the individual to ensure that the individual
remains stabilized during the period described in paragraph
(4).
``(B) Post-stabilization care.--The term `post-
stabilization care' means, with respect to an individual who
is determined to be stable pursuant to a medical screening
examination or who is stabilized after provision of emergency
services, medically necessary items and services (other than
emergency services and other than maintenance care) that are
required by the individual.
``(4) Period of required coverage of maintenance care.--The
period of required coverage of maintenance care of an
individual under this subsection begins at the time of the
request (or the initiation of the good faith effort to make
the request) under paragraph (1)(C) and ends when--
``(A) the individual is discharged from the hospital;
``(B) a physician (designated by the managed care entity
involved) and with privileges at the hospital involved
arrives at the emergency department of the hospital and
assumes responsibility with respect to the treatment of the
individual; or
``(C) the treating physician and the entity agree to
another arrangement with respect to the care of the
individual.
``(5) When post-stabilization care required to be
covered.--
``(A) When treating physician unable to communicate
request.--If the treating physician or other individual makes
the good faith effort to request authorization under
paragraph (1)(C) but is unable to communicate the request
directly with an authorized person referred to in such
paragraph within 30 minutes after the time of initiating such
effort, then post-stabilization care is required to be
covered under this subsection beginning at the end of such
30-minute period.
``(B) When able to communicate request, and no timely
response.--
``(i) In general.--If the treating physician or other
individual under paragraph (1)(C) is able to communicate the
request within the 30-minute period described in subparagraph
(A), the post-stabilization care requested is required to be
covered under this subsection beginning 30 minutes after the
time when the entity receives the request unless a person
authorized by the entity involved communicates (or makes a
good faith effort to communicate) a denial of the request for
the prior authorization determination within 30 minutes of
the time when the entity receives the request and the
treating physician does not request under clause (ii) to
communicate directly with an authorized physician concerning
the denial.
``(ii) Request for direct physician-to-physician
communication concerning denial.--If a denial of a request is
communicated under clause (i), the treating physician may
request to communicate respecting the denial directly with a
physician who is authorized by the entity to deny or affirm
such a denial.
``(C) When no timely response to request for physician-to-
physician communication.--If a request for physician-to-
physician communication is made under subparagraph (B)(ii),
the post-stabilization care requested is required to be
covered under this subsection beginning 30 minutes after the
time when the entity receives the request from a treating
physician unless a physician, who is authorized by the entity
to reverse or affirm the initial denial of the care,
communicates (or makes a good faith effort to communicate)
directly with the treating physician within such 30-minute
period.
``(D) Disagreements over post-stabilization care.--If,
after a direct physician-to-physician communication under
subparagraph (C), the denial of the request for the post-
stabilization care is not reversed and the treating physician
communicates to the entity involved a disagreement with such
decision, the post-stabilization care requested is required
to be covered under this subsection beginning as follows:
``(i) Delay to allow for prompt arrival of physician
assuming responsibility.--If the issuer communicates that a
physician (designated by the entity) with privileges at the
hospital involved will arrive promptly (as determined under
guidelines) at the emergency department of the hospital in
order to assume responsibility with respect to the treatment
of the enrollee involved, the required coverage of the post-
stabilization care begins after the passage of such time
period as would allow the prompt arrival of such a physician.
``(ii) Other cases.--If the entity does not so communicate,
the required coverage of
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the post-stabilization care begins immediately.
``(6) No requirement of coverage of post-stabilization care
if alternate plan of treatment.--
``(A) In general.--Coverage of post-stabilization care is
not required under this subsection with respect to an
individual when--
``(i) subject to subparagraph (B), a physician (designated
by the entity involved) and with privileges at the hospital
involved arrives at the emergency department of the hospital
and assumes responsibility with respect to the treatment of
the individual; or
``(ii) the treating physician and the entity agree to
another arrangement with respect to the post-stabilization
care (such as an appropriate transfer of the individual
involved to another facility or an appointment for timely
followup treatment for the individual).
``(B) Special rule where once care initiated.--Required
coverage of requested post-stabilization care shall not end
by reason of subparagraph (A)(i) during an episode of care
(as determined by guidelines) if the treating physician
initiated such care (consistent with a previous paragraph)
before the arrival of a physician described in such
subparagraph.
``(7) Construction.--Nothing in this subsection shall be
construed as--
``(A) preventing a managed care entity from authorizing
coverage of maintenance care or post-stabilization care in
advance or at any time; or
``(B) preventing a treating physician or other individual
described in paragraph (1)(C) and such an entity from
agreeing to modify any of the time periods specified in
paragraphs (5) as it relates to cases involving such persons.
``(c) Information on Access to Emergency Services.--A
managed care entity, to the extent the entity offers health
insurance coverage, shall provide education to enrollees on--
``(1) coverage of emergency services (as defined in
subsection (a)(2)(B)) by the entity in accordance with the
provisions of this section,
``(2) the appropriate use of emergency services, including
use of the 911 telephone system or its local equivalent,
``(3) any cost sharing applicable to emergency services,
``(4) the process and procedures of the plan for obtaining
emergency services, and
``(5) the locations of--
``(A) emergency departments, and
``(B) other settings,
in which participating physicians and hospitals provide
emergency services and post-stabilization care.
``(d) General Definitions.--For purposes of this section:
``(1) Cost sharing.--The term `cost sharing' means any
deductible, coinsurance amount, copayment or other out-of-
pocket payment (other than premiums or enrollment fees) that
a managed care entity issuer imposes on enrollees with
respect to the coverage of benefits.
``(2) Good faith effort.--The term `good faith effort' has
the meaning given such term in guidelines and requires such
appropriate documentation as is specified under such
guidelines.
``(3) Guidelines.--The term `guidelines' means guidelines
established by the Secretary after consultation with an
advisory panel that includes individuals representing
emergency physicians, managed care entities, including at
least one health maintenance organization, hospitals,
employers, the States, and consumers.
``(4) Prior authorization determination.--The term `prior
authorization determination' means, with respect to items and
services for which coverage may be provided by a managed are
entity, a determination (before the provision of the items
and services and as a condition of coverage of the items and
services under the coverage) of whether or not such items and
services will be covered under the coverage.
``(5) Stabilize.--The term `to stabilize' means, with
respect to an emergency medical condition, to provide (in
complying with section 1867 of the Social Security Act) such
medical treatment of the condition as may be necessary to
assure, within reasonable medical probability, that no
material deterioration of the condition is likely to result
from or occur during the transfer of the individual from the
facility.
``(6) Stabilized.--The term `stabilized' means, with
respect to an emergency medical condition, that no material
deterioration of the condition is likely, within reasonable
medical probability, to result from or occur before an
individual can be transferred from the facility, in
compliance with the requirements of section 1867 of the
Social Security Act.
``(7) Treating physician.--The term `treating physician'
includes a treating health care professional who is licensed
under State law to provide emergency services other than
under the supervision of a physician.
``SEC. 1944. OTHER BENEFICIARY PROTECTIONS.
``(a) Protecting Enrollees Against the Insolvency of
Managed Care Entities and Against the Failure of the State to
Pay Such Entities.--Each managed care entity shall provide
that an individual eligible for medical assistance under the
State plan under this title who is enrolled with the entity
may not be held liable--
``(1) for the debts of the managed care entity, in the
event of the medicaid managed care organization's insolvency;
``(2) for services provided to the individual--
``(A) in the event of the medicaid managed care
organization failing to receive payment from the State for
such services; or
``(B) in the event of a health care provider with a
contractual or other arrangement with the medicaid managed
care organization failing to receive payment from the State
or the managed care entity for such services; or
``(3) for the debts of any health care provider with a
contractual or other arrangement with the medicaid managed
care organization to provide services to the individual, in
the event of the insolvency of the health care provider.
``(b) Protection of Beneficiaries Against Balance Billing
Through Subcontractors.--
``(1) In general.--Any contract between a managed care
entity that has an agreement with a State under this title
and another entity under which the entity (or any other
entity pursuant to the contract) provides directly or
indirectly for the provision of services to beneficiaries
under the agreement with the State shall include such
provisions as the Secretary may require in order to assure
that the entity complies with balance billing limitations and
other requirements of this title (such as limitation on
withholding of services) as they would apply to the managed
care entity if such entity provided such services directly
and not through a contract with another entity.
``(2) Application of sanctions for violations.--The
provisions of section 11
Major Actions:
All articles in Senate section
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
(Senate - June 10, 1997)
Text of this article available as:
TXT
PDF
[Pages
S5444-S5464]
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
By Mr. MOYNIHAN (for himself and Mr. Sarbames):
S. 863. A bill to authorize the Government of India to establish a
memorial to honor Mahatma Gandhi in the District of Columbia; to the
Committee on Energy and Natural Resources.
Legislation to Establish Mahatma Gandhi Memorial
Mr. MOYNIHAN. Mr. President, I rise to introduce a bill to authorize
the placement of a statue of Mohandas Karamchand Gandhi --Mahatma
Gandhi--on Federal land across the street from the Indian embassy in
Washington DC. The Government of India has offered a statue of Gandhi
as a gift to the United States. In order to place it on Federal land,
an act of Congress is required. This bill will fulfill just that
purpose, and I thank the Senator from Florida [Mr. Mack] and the
Senator from Maryland, [Mr. Sarbanes] for joining me in this endeavor.
India is currently celebrating the 50th anniversary of its
independence. Authorizing the placement of a statue of Mahatma Gandhi,
often called the father of the Indian nation, would serve as a fitting
tribute to Indian democracy which has survived--in fact, thrived--
despite enormous challenges, and a symbol of the growing strength of
the bonds between our two countries.
It is particularly appropriate that a statue of Mahatma Gandhi be
selected for this purpose. The effects of his non-
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violent actions and the philosophy which guided them were not limited
to his country, nor his time. His influence in the United States was
most notably felt in the civil rights movement, but has also infused
all levels of our society.
If I may invade ever so slightly the privacy of the President's
luncheon table, in May 1994, Mr. Clinton had as his guest the
distinguished Prime Minister of India, Mr. P.V. Narasimha Rao, who in
his youth was a follower of Mahatma Gandhi. In a graceful passage,
Prime Minister Rao related how it came to pass that Mahatma Gandhi,
caught up in the struggle for fair treatment to the Indian community in
South Africa, and in consequence in jail, read Thoreau's essay on
``Civil Disobedience'' which confirmed his view that an honest man is
duty-bound to violate unjust laws. He took this view home with him, and
in the end the British raj gave way to an independent Republic of
India. Then Martin Luther King, Jr., repatriated the idea and so began
the great civil rights movement of this century.
Dr. Martin Luther King, Jr., has written of the singular influence
Gandhi's message of nonviolent resistance had on him when he first
learned of it while studying at Crozier Theological Seminary in
Philadelphia. He would later describe that influence in his first book,
``Stride Toward Freedom'':
As I read I became deeply fascinated by [Gandhi's]
philosophy of non-violent resistance . . . as I delved deeper
into the philosophy of Gandhi, my skepticism concerning the
power of love gradually diminished, and I came to see its
potency in the area of social reform . . . prior to reading
Gandhi, I had concluded that the love ethics of Jesus were
only effective in individual relationships . . . but after
reading Gandhi, I saw how utterly mistaken I was.
. . . It was in this Gandhian emphasis on love and non-
violence that I discovered the method for social reform that
I had been seeking for so many months . . . I came to feel
that this was the only morally and practically sound method
open to oppressed people in their struggle for freedom . . .
this principle became the guiding light of our movement.
Christ furnished the spirit and motivation and Gandhi
furnished the method.
Martin Luther King, Jr., believed that Gandhi's philosophy of
nonviolent resistance was the guiding light of the American civil
rights movement. As Dr. King wrote, ``Gandhi furnished the message.'' A
statue of Gandhi, given as a gift from the Government of India, on a
small plot of Federal land along Massachusetts Avenue, in front of the
Indian Embassy, will stand not only as a tribute to the shared values
of the two largest democracies in the world but will also pay tribute
to the lasting influence of Gandhian thought on the United States. An
influence that is so pervasive that when the President and the Prime
Minister of India meet at the White House for lunch, a half-century
after Gandhi's death, it is no surprise that he should be a topic of
conversation.
______
By Mr. CHAFEE (for himself, Mr. Breaux, Mr. Kerrey, and Mr.
Conrad):
S. 864. A bill to amend title XIX of the Social Security Act to
improve the provision of managed care under the Medicaid Program; to
the Committee on Finance.
The Medicaid Managed Care Act of 1997
Mr. CHAFEE. Mr. President, I am pleased today to introduce The
Medicaid Managed Care Act of 1997. This legislation meets two very
important objectives in the Medicaid Program. First, it gives States
the additional flexibility they need to administer the Medicaid Program
by allowing them to enroll Medicaid beneficiaries into managed care
Programs. Second, the bill sets Federal standards for managed care to
ensure that Medicaid patients receive the same quality of care as those
patients who are enrolled in private managed care plans.
Under our legislation, States could require Medicaid patients to
enroll in managed care plans without going through the lengthy and
cumbersome process of applying to the Secretary of Health and Human
Services for a waiver of current Medicaid regulations. In exchange for
this important flexibility, States will have to meet a set of minimum
Federal standards to ensure that Medicaid patients continue to receive
quality care.
For example, States would be required to offer patients a choice of
at least two health plans. Plans would be required to meet certain
standards of access to care, quality, and solvency. These standards are
especially important given recent problems in States that have set up
Medicaid managed care programs under the waiver process. In some
instances, plans have failed to contract with enough providers to serve
the Medicaid population. Some have been permitted to operate under
standards that are lower than commercial insurers are required to meet,
and others have used fraudulent marketing practices to entice Medicaid
patients to sign up with their plans. These actions have resulted in
patients being denied medically necessary services, and have resulted
in States and the Federal Government paying for care that was never
given.
Considering these abuses, why should we allow Medicaid managed care
at all? Because managed care, if implemented correctly, can vastly
improve the quality of health care provided to low-income families. In
today's fee-for-service program, patients face myriad problems. Some
are forced to get care in hospital emergency rooms because they cannot
find a private physician willing or able to accept Medicaid's low
payment rates. Those who do have access to providers often must wait
for hours in clinics which are overcrowded and understaffed. And,
sadly, they often do not have access to primary and preventive care
services which would have prevented them from becoming ill to begin
with.
Medicaid managed care, if done well, provides regular prenatal care
to assure that children are born healthy. These plans provide coverage
for check-ups and immunizations to prevent serious illnesses. And they
give patients a medical home--a provider they know they can go to if
they are sick, or a number to call if they have questions.
Medicaid managed care also has the potential of benefiting our
overall health care system by providing access to primary care
providers rather than forcing patients to make costly and unnecessary
visits to hospital emergency rooms. It gives providers the opportunity
to catch and treat, or prevent, costly health problems.
Mr. President, we have worked very hard to ensure that this
legislation strikes an appropriate balance between the needs of
Medicaid beneficiaries and the managed care companies. I want to thank
Senators Breaux and Kerrey who helped craft this legislation and are
original cosponsors. I also want to thank the many advocacy
organizations for their input and support. And I also want to thank
some of the managed care organizations who worked with us. I am
especially pleased that some of these organizations, such as the HMO
Group which is an alliance of health maintenance organizations have
endorsed this legislation. Their support is critical to the success of
Medicaid managed care.
I ask unanimous consent that the text of the legislation be included
in the Record.
There being no objection, the bill was ordered to be printed in the
Record, as follows:
S. 864
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS; AMENDMENTS TO THE
SOCIAL SECURITY ACT.
(a) Short Title.--This Act may be cited as the ``Medicaid
Managed Care Improvement Act of 1997''.
(b) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents; amendments to the Social
Security Act.
Sec. 2. Improvements in medicaid managed care program.
``Part B--Provisions Relating to Managed Care
``Sec. 1941. Beneficiary choice; enrollment.
``Sec. 1942. Beneficiary access to services generally.
``Sec. 1943. Beneficiary access to emergency care.
``Sec. 1944. Other beneficiary protections.
``Sec. 1945. Assuring quality care.
``Sec. 1946. Protections for providers.
``Sec. 1947. Assuring adequacy of payments to medicaid managed care
organizations and entities.
``Sec. 1948. Fraud and abuse.
``Sec. 1949. Sanctions for noncompliance by managed care entities.
``Sec. 1950. Definitions; miscellaneous provisions.''
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Sec. 3. Studies and reports.
Sec. 4. Conforming amendments.
Sec. 5. Effective date; status of waivers.
(c) Amendments to Social Security Act.--Except as otherwise
specifically provided, whenever in this Act an amendment is
expressed in terms of an amendment to or repeal of a section
or other provision, the reference shall be considered to be
made to that section or other provision of the Social
Security Act.
SEC. 2. IMPROVEMENTS IN MEDICAID MANAGED CARE PROGRAM.
Title XIX is amended--
(1) by inserting after the title heading the following:
``Part A--General Provisions''; and
(2) by adding at the end the following new part:
``Part B--Provisions Relating to Managed Care
``SEC. 1941. BENEFICIARY CHOICE; ENROLLMENT.
``(a) State Options for Enrollment of Beneficiaries in
Managed Care Arrangements.--
``(1) In general.--Subject to the succeeding provisions of
this part and notwithstanding paragraphs (1), (10)(B), and
(23)(A) of section 1902(a), a State may require an individual
who is eligible for medical assistance under the State plan
under this title and who is not a special needs individual
(as defined in subsection (e)) to enroll with a managed care
entity (as defined in section 1950(a)(1)) as a condition of
receiving such assistance (and, with respect to assistance
furnished by or under arrangements with such entity, to
receive such assistance through the entity), if the following
provisions are met:
``(A) Entity meets requirements.--The entity meets the
applicable requirements of this part.
``(B) Contract with state.--The entity enters into a
contract with the State to provide services for the benefit
of individuals eligible for benefits under this title under
which prepaid payments to such entity are made on an
actuarially sound basis. Such contract shall specify benefits
the provision (or arrangement) for which the entity is
responsible.
``(C) Choice of coverage.--
``(i) In general.--The State permits an individual to
choose a managed care entity from managed care organizations
and primary care case providers who meet the requirements of
this part but not less than from--
``(I) 2 medicaid managed care organizations,
``(II) a medicaid managed care organization and a primary
care case management provider, or
``(III) a primary care case management provider as long as
an individual may choose between 2 primary care case
managers.
``(ii) State option.--At the option of the State, a State
shall be considered to meet the requirements of clause (i) in
the case of an individual residing in a rural area, if the
State--
``(I) requires the individual to enroll with a medicaid
managed care organization or primary care case management
provider if such organization or entity permits the
individual to receive such assistance through not less than 2
physicians or case managers (to the extent that at least 2
physicians or case managers are available to provide such
assistance in the area), and
``(II) permits the individual to obtain such assistance
from any other provider in appropriate circumstances (as
established by the State under regulations of the Secretary).
``(D) Changes in enrollment.--The State provides the
individual with the opportunity to change enrollment among
managed care entities once annually and notifies the
individual of such opportunity not later than 60 days prior
to the first date on which the individual may change
enrollment, permits individuals to change their enrollment
for cause at any time and without cause at least every 12
months, and allows individuals to disenroll without cause
within 90 days of notification of enrollment.
``(E) Enrollment priorities.--The State establishes a
method for establishing enrollment priorities in the case of
a managed care entity that does not have sufficient capacity
to enroll all such individuals seeking enrollment under which
individuals already enrolled with the entity are given
priority in continuing enrollment with the entity.
``(F) Default enrollment process.--The State establishes a
default enrollment process which meets the requirements
described in paragraph (2) and under which any such
individual who does not enroll with a managed care entity
during the enrollment period specified by the State shall be
enrolled by the State with such an entity in accordance with
such process.
``(G) Sanctions.--The State establishes the sanctions
provided for in section 1949.
``(2) Default enrollment process requirements.--The default
enrollment process established by a State under paragraph
(1)(F)--
``(A) shall provide that the State may not enroll
individuals with a managed care entity which is not in
compliance with the applicable requirements of this part;
``(B) shall provide (consistent with subparagraph (A)) for
enrollment of such an individual with a medicaid managed care
organization--
``(i) first, that maintains existing provider-individual
relationships or that has entered into contracts with
providers (such as Federally qualified health centers, rural
health clinics, hospitals that qualify for disproportionate
share hospital payments under section 1886(d)(5)(F), and
hospitals described in section 1886(d)(1)(B)(iii)) that have
traditionally served beneficiaries under this title, and
``(ii) lastly, if there is no provider described in clause
(i), in a manner that provides for an equitable distribution
of individuals among all qualified managed care entities
available to enroll individuals through such default
enrollment process, consistent with the enrollment capacities
of such entities;
``(C) shall permit and assist an individual enrolled with
an entity under such process to change such enrollment to
another managed care entity during a period (of at least 90
days) after the effective date of the enrollment; and
``(D) may provide for consideration of factors such as
quality, geographic proximity, continuity of providers, and
capacity of the plan when conducting such process.
``(b) Reenrollment of Individuals Who Regain Eligibility.--
``(1) In general.--If an individual eligible for medical
assistance under a State plan under this title and enrolled
with a managed care entity with a contract under subsection
(a)(1)(B) ceases to be eligible for such assistance for a
period of not greater than 2 months, the State may provide
for the automatic reenrollment of the individual with the
entity as of the first day of the month in which the
individual is again eligible for such assistance, and may
consider factors such as quality, geographic proximity,
continuity of providers, and capacity of the plan when
conducting such reenrollment.
``(2) Conditions.--Paragraph (1) shall only apply if--
``(A) the month for which the individual is to be
reenrolled occurs during the enrollment period covered by the
individual's original enrollment with the managed care
entity;
``(B) the managed care entity continues to have a contract
with the State agency under subsection (a)(1)(B) as of the
first day of such month; and
``(C) the managed care entity complies with the applicable
requirements of this part.
``(3) Notice of reenrollment.--The State shall provide
timely notice to a managed care entity of any reenrollment of
an individual under this subsection.
``(c) State Option of Minimum Enrollment Period.--
``(1) In general.--In the case of an individual who is
enrolled with a managed care entity under this part and who
would (but for this subsection) lose eligibility for benefits
under this title before the end of the minimum enrollment
period (defined in paragraph (2)), the State plan under this
title may provide, notwithstanding any other provision of
this title, that the individual shall be deemed to continue
to be eligible for such benefits until the end of such
minimum period, but, except for benefits furnished under
section 1902(a)(23)(B), only with respect to such benefits
provided to the individual as an enrollee of such entity.
``(2) Minimum enrollment period defined.--For purposes of
paragraph (1), the term `minimum enrollment period' means,
with respect to an individual's enrollment with an entity
under a State plan, a period, established by the State, of
not more than 6 months beginning on the date the individual's
enrollment with the entity becomes effective, except that a
State may extend such period for up to a total of 12 months
in the case of an individual's enrollment with a managed care
entity (as defined in section 1950(a)(1)) so long as such
extension is done uniformly for all individuals enrolled with
all such entities.
``(d) Other Enrollment-Related Provisions.--
``(1) Nondiscrimination.--A managed care entity may not
discriminate on the basis of health status or anticipated
need for services in the enrollment, reenrollment, or
disenrollment of individuals eligible to receive medical
assistance under a State plan under this title or by
discouraging enrollment (except as permitted by this section)
by eligible individuals.
``(2) Termination of enrollment.--
``(A) In general.--The State, enrollment broker, and
managed care entity (if any) shall permit an individual
eligible for medical assistance under the State plan under
this title who is enrolled with the entity to terminate such
enrollment for cause at any time, and without cause during
the 90-day period beginning on the date the individual
receives notice of enrollment and at least every 12 months
thereafter, and shall notify each such individual of the
opportunity to terminate enrollment under these conditions.
``(B) Fraudulent inducement or coercion as grounds for
cause.--For purposes of subparagraph (A), an individual
terminating enrollment with a managed care entity on the
grounds that the enrollment was based on fraudulent
inducement or was obtained through coercion or pursuant to
the imposition against the managed care entity of the
sanction described in section 1949(b)(3) shall be considered
to terminate such enrollment for cause.
``(C) Notice of termination.--
``(i) Notice to state.--
``(I) By individuals.--Each individual terminating
enrollment with a managed care entity under subparagraph (A)
shall do so by
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providing notice of the termination to an office of the State
agency administering the State plan under this title, the
State or local welfare agency, or an office of a managed care
entity.
``(II) By organizations.--Any managed care entity which
receives notice of an individual's termination of enrollment
with such entity through receipt of such notice at an office
of a managed care entity shall provide timely notice of the
termination to the State agency administering the State plan
under this title.
``(ii) Notice to plan.--The State agency administering the
State plan under this title or the State or local welfare
agency which receives notice of an individual's termination
of enrollment with a managed care entity under clause (i)
shall provide timely notice of the termination to such
entity.
``(3) Provision of information.--
``(A) In general.--Each State, enrollment broker, or
managed care organization shall provide all enrollment
notices and informational and instructional materials in a
manner and form which may be easily understood by enrollees
of the entity who are eligible for medical assistance under
the State plan under this title, including enrollees and
potential enrollees who are blind, deaf, disabled, or cannot
read or understand the English language.
``(B) Information to health care providers, enrollees, and
potential enrollees.--Each medicaid managed care organization
shall--
``(i) upon request, make the information described in
section 1945(e)(1)(A)available to enrollees and potential
enrollees in the organization's service area; and
``(ii) provide to enrollees and potential enrollees
information regarding all items and services that are
available to enrollees under the contract between the State
and the organization that are covered either directly or
through a method of referral and prior authorization.
``(e) Special Needs Individuals Described.--In this part,
the term `special needs individual' means any of the
following individuals:
``(1) Special needs child.--An individual who is under 19
years of age who--
``(A) is eligible for supplemental security income under
title XVI;
``(B) is described under section 501(a)(1)(D);
``(C) is a child described in section 1902(e)(3);
``(D) is receiving services under a program under part B or
part E of title IV; or
``(E) is not described in any preceding subparagraph but is
otherwise considered a child with special health care needs
who is adopted, in foster care, or otherwise in an out-of-
home placement.
``(2) Homeless individuals.--An individual who is homeless
(without regard to whether the individual is a member of a
family), including--
``(A) an individual whose primary residence during the
night is a supervised public or private facility that
provides temporary living accommodations; or
``(B) an individual who is a resident in transitional
housing.
``(3) Migrant agricultural workers.--A migratory
agricultural worker or a seasonal agricultural worker (as
such terms are defined in section 330(g)(3) of the Public
Health Service Act), or the spouse or dependent of such a
worker.
``(4) Indians.--An Indian (as defined in section 4(c) of
the Indian Health Care Improvement Act (25 U.S.C. 1603(c))).
``(5) Medicare beneficiaries.--A qualified medicare
beneficiary (as defined in section 1905(p)(1)) or an
individual otherwise eligible for benefits under title XVIII.
``(6) Disabled individuals.--Individuals who are disabled
(as determined under section 1614(a)(3)).
``(7) Persons with aids or hiv infection.--An individual
with acquired immune deficiency syndrome (AIDS) or who has
been determined to be infected with the HIV virus.
``SEC. 1942. BENEFICIARY ACCESS TO SERVICES GENERALLY.
``(a) Access to Services.--
``(1) In general.--Each managed care entity shall provide
or arrange for the provision of all medically necessary
medical assistance under this title which is specified in the
contract entered into between such entity and the State under
section 1941(a)(1)(B) for enrollees who are eligible for
medical assistance under the State plan under this title.
``(2) Primary-care-provider-to-enrollee ratio and maximum
travel time.--Each such entity shall assure adequate access
to primary care services by meeting standards, established by
the Secretary, relating to the maximum ratio of enrollees
under this title to full-time-equivalent primary care
providers available to serve such enrollees and to maximum
travel time for such enrollees to access such providers. The
Secretary may permit such a maximum ratio to vary depending
on the area and population served. Such standards shall be
based on standards commonly applied in the commercial market,
commonly used in accreditation of managed care organizations,
and standards used in the approval of waiver applications
under section 1115, and shall be consistent with the
requirements under section 1876(c)(4)(A).
``(b) Obstetrical and Gynecological Care.--
``(1) In general.--A managed care entity may not require
prior authorization by the individual's primary care provider
or otherwise restrict the individual's access to
gynecological and obstetrical care provided by a
participating provider who specializes in obstetrics and
gynecology to the extent such care is otherwise covered, and
may treat the ordering of other obstetrical and gynecological
care by such a participating provider as the prior
authorization of the primary care provider with respect to
such care under the coverage.
``(2) Construction.--Nothing in paragraph (1)(B)(ii) shall
waive any requirements of coverage relating to medical
necessity or appropriateness with respect to coverage of
gynecological care so ordered.
``(c) Specialty Care.--
``(1) Referral to specialty care for enrollees requiring
treatment by specialists.--
``(A) In general.--In the case of an enrollee under a
managed care entity and who has a condition or disease of
sufficient seriousness and complexity to require treatment by
a specialist, the entity shall make or provide for a referral
to a specialist who is available and accessible to provide
the treatment for such condition or disease.
``(B) Specialist defined.--For purposes of this subsection,
the term `specialist' means, with respect to a condition, a
health care practitioner, facility, or center (such as a
center of excellence) that has adequate expertise through
appropriate training and experience (including, in the case
of a child, an appropriate pediatric specialist) to provide
high quality care in treating the condition.
``(C) Care under referral.--Care provided pursuant to such
referral under subparagraph (A) shall be--
``(i) pursuant to a treatment plan (if any) developed by
the specialist and approved by the entity, in consultation
with the designated primary care provider or specialist and
the enrollee (or the enrollee's designee), and
``(ii) in accordance with applicable quality assurance and
utilization review standards of the entity.
Nothing in this subsection shall be construed as preventing
such a treatment plan for an enrollee from requiring a
specialist to provide the primary care provider with regular
updates on the specialty care provided, as well as all
necessary medical information.
``(D) Referrals to participating providers.--An entity is
not required under subparagraph (A) to provide for a referral
to a specialist that is not a participating provider, unless
the entity does not have an appropriate specialist that is
available and accessible to treat the enrollee's condition
and that is a participating provider with respect to such
treatment.
``(E) Treatment of nonparticipating providers.--If an
entity refers an enrollee to a nonparticipating specialist,
services provided pursuant to the approved treatment plan
shall be provided at no additional cost to the enrollee
beyond what the enrollee would otherwise pay for services
received by such a specialist that is a participating
provider.
``(2) Specialists as primary care providers.--
``(A) In general.--A managed care entity shall have a
procedure by which a new enrollee upon enrollment, or an
enrollee upon diagnosis, with an ongoing special condition
(as defined in subparagraph (C)) may receive a referral to a
specialist for such condition who shall be responsible for
and capable of providing and coordinating the enrollee's
primary and specialty care. If such an enrollee's care would
most appropriately be coordinated by such a specialist, the
entity shall refer the enrollee to such specialist.
``(B) Treatment as primary care provider.--Such specialist
shall be permitted to treat the enrollee without a referral
from the enrollee's primary care provider and may authorize
such referrals, procedures, tests, and other medical services
as the enrollee's primary care provider would otherwise be
permitted to provide or authorize, subject to the terms of
the treatment plan (referred to in paragraph (1)(C)(i)).
``(C) Ongoing special condition defined.--In this
paragraph, the term `special condition' means a physical and
mental condition or disease that--
``(i) is life-threatening, degenerative, or disabling, and
``(ii) requires specialized medical care over a prolonged
period of time.
``(D) Terms of referral.--The provisions of subparagraphs
(C) through (E) of paragraph (1) shall apply with respect to
referrals under subparagraph (A) of this paragraph in the
same manner as they apply to referrals under paragraph
(1)(A).
``(3) Standing referrals.--
``(A) In general.--A managed care entity shall have a
procedure by which an enrollee who has a condition that
requires ongoing care from a specialist may receive a
standing referral to such specialist for treatment of such
condition. If the issuer, or the primary care provider in
consultation with the medical director of the entity and the
specialist (if any), determines that such a standing referral
is appropriate, the entity shall make such a referral to such
a specialist.
``(B) Terms of referral.--The provisions of subparagraphs
(C) through (E) of paragraph (1) shall apply with respect to
referrals under subparagraph (A) of this paragraph in the
same manner as they apply to referrals under paragraph
(1)(A).
``(d) Timely Delivery of Services.--Each managed care
entity shall respond to requests from enrollees for the
delivery of medical assistance in a manner which--
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``(1) makes such assistance--
``(A) available and accessible to each such individual,
within the area served by the entity, with reasonable
promptness and in a manner which assures continuity; and
``(B) when medically necessary, available and accessible 24
hours a day and 7 days a week; and
``(2) with respect to assistance provided to such an
individual other than through the entity, or without prior
authorization, in the case of a primary care case management
provider, provides for reimbursement to the individual (if
applicable under the contract between the State and the
entity) if--
``(A) the services were medically necessary and immediately
required because of an unforeseen illness, injury, or
condition and meet the requirements of section 1943; and
``(B) it was not reasonable given the circumstances to
obtain the services through the entity, or, in the case of a
primary care case management provider, with prior
authorization.
``(e) Internal Grievance Procedure.--Each medicaid managed
care organization shall establish an internal grievance
procedure under which an enrollee who is eligible for medical
assistance under the State plan under this title, or a
provider on behalf of such an enrollee, may challenge the
denial of coverage of or payment for such assistance.
``(f) Information on Benefit Carve Outs.--Each managed care
entity shall inform each enrollee, in a written and prominent
manner, of any benefits to which the enrollee may be entitled
to medical assistance under this title but which are not made
available to the enrollee through the entity. Such
information shall include information on where and how such
enrollees may access benefits not made available to the
enrollee through the entity.
``(g) Due Process Requirements for Managed Care Entities.--
``(1) Denial of or unreasonable delay in determining
coverage as grounds for hearing.--If a managed care entity
(or entity acting an agreement with a managed care entity)--
``(A) denies coverage of or payment for medical assistance
with respect to an enrollee who is eligible for such
assistance under the State plan under this title; or
``(B) fails to make any eligibility or coverage
determination sought by an enrollee or, in the case of a
medicaid managed care organization, by a participating health
care provider or enrollee, in a timely manner, depending upon
the urgency of the situation,
the enrollee or the health care provider furnishing such
assistance to the enrollee (as applicable) may obtain a fair
hearing before, and shall be provided a timely decision by,
the State agency administering the State plan under this
title in accordance with section 1902(a)(3). Such decisions
shall be rendered as soon as possible in accordance with the
medical exigencies of the cases, and in no event later than
72 hours in the case of hearings on decisions regarding
urgent care and 5 days in the case of all other hearings.
``(2) Completion of internal grievance procedure.--Nothing
in this subsection shall require completion of an internal
grievance procedure if the procedure does not provide for
timely review of health needs considered by the enrollee's
health care provider to be of an urgent nature or is not
otherwise consistent with the requirements for such
procedures under section 1876(c).
``(h) Demonstration of Adequate Capacity and Services.--
``(1) In general.--Subject to paragraph (3), each medicaid
managed care organization shall provide the State and the
Secretary with adequate assurances (as determined by the
Secretary) that the organization, with respect to a service
area--
``(A) has the capacity to serve the expected enrollment in
such service area;
``(B) offers an appropriate range of services for the
population expected to be enrolled in such service area,
including transportation services and translation services
consisting of the principal languages spoken in the service
area;
``(C) maintains a sufficient number, mix, and geographic
distribution of providers of services included in the
contract with the State to ensure that services are available
to individuals receiving medical assistance and enrolled in
the organization to the same extent that such services are
available to individuals enrolled in the organization who are
not recipients of medical assistance under the State plan
under this title;
``(D) maintains extended hours of operation with respect to
primary care services that are beyond those maintained during
a normal business day;
``(E) provides preventive and primary care services in
locations that are readily accessible to members of the
community;
``(F) provides information concerning educational, social,
health, and nutritional services offered by other programs
for which enrollees may be eligible; and
``(G) complies with such other requirements relating to
access to care as the Secretary or the State may impose.
``(2) Proof of adequate primary care capacity and
services.--Subject to paragraph (3), a medicaid managed care
organization that contracts with a reasonable number of
primary care providers (as determined by the Secretary) and
whose primary care membership includes a reasonable number
(as so determined) of the following providers will be deemed
to have satisfied the requirements of paragraph (1):
``(A) Rural health clinics, as defined in section
1905(l)(1).
``(B) Federally-qualified health centers, as defined in
section 1905(l)(2)(B).
``(C) Clinics which are eligible to receive payment for
services provided under title X of the Public Health Service
Act.
``(3) Sufficient providers of specialized services.--
Notwithstanding paragraphs (1) and (2), a medicaid managed
care organization may not be considered to have satisfied the
requirements of paragraph (1) if the organization does not
have a sufficient number (as determined by the Secretary) of
providers of specialized services, including perinatal and
pediatric specialty care, to ensure that such services are
available and accessible.
``(i) Compliance With Certain Maternity and Mental Health
Requirements.--Each medicaid managed care organization shall
comply with the requirements of subpart 2 of part A of title
XXVII of the Public Health Service Act insofar as such
requirements apply with respect to a health insurance issuer
that offers group health insurance coverage.
``(j) Treatment of Children With Special Health Care
Needs.--
``(1) In general.--In the case of an enrollee of a managed
care entity who is a child described in section 1941(e)(1) or
who has special health care needs (as defined in paragraph
(3))--
``(A) if any medical assistance specified in the contract
with the State is identified in a treatment plan prepared for
the enrollee by a program described in subsection (c)(1) or
paragraph (3), the managed care entity shall provide (or
arrange to be provided) such assistance in accordance with
the treatment plan either--
``(i) by referring the enrollee to a pediatric health care
provider who is trained and experienced in the provision of
such assistance and who has a contract with the managed care
entity to provide such assistance; or
``(ii) if appropriate services are not available through
the managed care entity, permitting such enrollee to seek
appropriate specialty services from pediatric health care
providers outside of or apart from the managed care entity;
and
``(B) the managed care entity shall require each health
care provider with whom the managed care entity has entered
into an agreement to provide medical assistance to enrollees
to furnish the medical assistance specified in such
enrollee's treatment plan to the extent the health care
provider is able to carry out such treatment plan.
``(2) Prior authorization.--An enrollee referred for
treatment under paragraph (1)(A)(i), or permitted to seek
treatment outside of or apart from the managed care entity
under paragraph (1)(A)(ii) shall be deemed to have obtained
any prior authorization required by the entity.
``(3) Child with special health care needs.--For purposes
of paragraph (1), a child has special health care needs if
the child is receiving services under--
``(A) a program administered under part B or part H of the
Individuals with Disabilities Education Act; or
``(B) any other program for children with special health
care needs identified by the Secretary.
``SEC. 1943. BENEFICIARY ACCESS TO EMERGENCY CARE.
``(a) Prohibition of Certain Restrictions on Coverage of
Emergency Services.--
``(1) In general.--If a managed care entity provides any
benefits under a State plan with respect to emergency
services (as defined in paragraph (2)(B)), the entity shall
cover emergency services furnished to an enrollee--
``(A) without the need for any prior authorization
determination,
``(B) subject to paragraph (3), whether or not the
physician or provider furnishing such services is a
participating physician or provider with respect to such
services, and
``(C) subject to paragraph (3), without regard to any other
term or condition of such coverage (other than an exclusion
of benefits).
``(2) Emergency services; emergency medical condition.--For
purposes of this section--
``(A) Emergency medical condition based on prudent
layperson.--The term `emergency medical condition' means a
medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a
prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of
immediate medical attention to result in--
``(i) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy,
``(ii) serious impairment to bodily functions, or
``(iii) serious dysfunction of any bodily organ or part.
``(B) Emergency services.--The term `emergency services'
means--
``(i) a medical screening examination (as required under
section 1867) that is within the capability of the emergency
department of a hospital, including ancillary services
routinely available to the emergency department, to evaluate
an emergency medical condition (as defined in subparagraph
(A)), and
``(ii) within the capabilities of the staff and facilities
available at the hospital, such further medical examination
and treatment as
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are required under section 1867 to stabilize the patient.
``(C) Trauma and burn centers.--The provisions of clause
(ii) of subparagraph (B) apply to a trauma or burn center, in
a hospital, that--
``(i) is designated by the State, a regional authority of
the State, or by the designee of the State, or
``(ii) is in a State that has not made such designations
and meets medically recognized national standards.
``(3) Application of network restriction permitted in
certain cases.--
``(A) In general.--Except as provided in subparagraph (B),
if a managed care entity in relation to benefits provided
under this title denies, limits, or otherwise differentiates
in benefits or payment for benefits other than emergency
services on the basis that the physician or provider of such
services is a nonparticipating physician or provider, the
entity may deny, limit, or differentiate in coverage or
payment for emergency services on such basis.
``(B) Network restrictions not permitted in certain
exceptional cases.--The denial or limitation of, or
differentiation in, coverage or payment of benefits for
emergency services under subparagraph (A) shall not apply in
the following cases:
``(i) Circumstances beyond control of enrollee.--The
enrollee is unable to go to a participating hospital for such
services due to circumstances beyond the control of the
enrollee (as determined consistent with guidelines and
subparagraph (C)).
``(ii) Likelihood of an adverse health consequence based on
layperson's judgment.--A prudent layperson possessing an
average knowledge of health and medicine could reasonably
believe that, under the circumstances and consistent with
guidelines, the time required to go to a participating
hospital for such services could result in any of the adverse
health consequences described in a clause of subsection
(a)(2)(A).
``(iii) Physician referral.--A participating physician or
other person authorized by the plan refers the enrollee to an
emergency department of a hospital and does not specify an
emergency department of a hospital that is a participating
hospital with respect to such services.
``(C) Application of `beyond control' standards.--For
purposes of applying subparagraph (B)(i), receipt of
emergency services from a nonparticipating hospital shall be
treated under the guidelines as being `due to circumstances
beyond the control of the enrollee' if any of the following
conditions are met:
``(i) Unconscious.--The enrollee was unconscious or in an
otherwise altered mental state at the time of initiation of
the services.
``(ii) Ambulance delivery.--The enrollee was transported by
an ambulance or other emergency vehicle directed by a person
other than the enrollee to the nonparticipating hospital in
which the services were provided.
``(iii) Natural disaster.--A natural disaster or civil
disturbance prevented the enrollee from presenting to a
participating hospital for the provision of such services.
``(iv) No good faith effort to inform of change in
participation during a contract year.--The status of the
hospital changed from a participating hospital to a
nonparticipating hospital with respect to emergency services
during a contract year and the entity failed to make a good
faith effort to notify the enrollee involved of such change.
``(v) Other conditions.--There were other factors (such as
those identified in guidelines) that prevented the enrollee
from controlling selection of the hospital in which the
services were provided.
``(b) Assuring Coordinated Coverage of Maintenance Care and
Post-Stabilization Care.--
``(1) In general.--In the case of an individual who is
enrolled with a managed care entity and who has received
emergency services pursuant to a screening evaluation
conducted (or supervised) by a treating physician at a
hospital that is a nonparticipating provider with respect to
emergency services, if--
``(A) pursuant to such evaluation, the physician identifies
post-stabilization care (as defined in paragraph (3)(B)) that
is required by the enrollee,
``(B) the coverage through the entity under this title
provides benefits with respect to the care so identified and
the coverage requires (but for this subsection) an
affirmative prior authorization determination as a condition
of coverage of such care, and
``(C) the treating physician (or another individual acting
on behalf of such physician) initiates, not later than 30
minutes after the time the treating physician determines that
the condition of the enrollee is stabilized, a good faith
effort to contact a physician or other person authorized by
the entity (by telephone or other means) to obtain an
affirmative prior authorization determination with respect to
the care,
then, without regard to terms and conditions specified in
paragraph (2) the entity shall cover maintenance care (as
defined in paragraph (3)(A)) furnished to the enrollee during
the period specified in paragraph (4) and shall cover post-
stabilization care furnished to the enrollee during the
period beginning under paragraph (5) and ending under
paragraph (6).
``(2) Terms and conditions waived.--The terms and
conditions (of coverage) described in this paragraph that are
waived under paragraph (1) are as follows:
``(A) The need for any prior authorization determination.
``(B) Any limitation on coverage based on whether or not
the physician or provider furnishing the care is a
participating physician or provider with respect to such
care.
``(C) Any other term or condition of the coverage (other
than an exclusion of benefits and other than a requirement
relating to medical necessity for coverage of benefits).
``(3) Maintenance care and post-stabilization care
defined.--In this subsection:
``(A) Maintenance care.--The term `maintenance care' means,
with respect to an individual who is stabilized after
provision of emergency services, medically necessary items
and services (other than emergency services) that are
required by the individual to ensure that the individual
remains stabilized during the period described in paragraph
(4).
``(B) Post-stabilization care.--The term `post-
stabilization care' means, with respect to an individual who
is determined to be stable pursuant to a medical screening
examination or who is stabilized after provision of emergency
services, medically necessary items and services (other than
emergency services and other than maintenance care) that are
required by the individual.
``(4) Period of required coverage of maintenance care.--The
period of required coverage of maintenance care of an
individual under this subsection begins at the time of the
request (or the initiation of the good faith effort to make
the request) under paragraph (1)(C) and ends when--
``(A) the individual is discharged from the hospital;
``(B) a physician (designated by the managed care entity
involved) and with privileges at the hospital involved
arrives at the emergency department of the hospital and
assumes responsibility with respect to the treatment of the
individual; or
``(C) the treating physician and the entity agree to
another arrangement with respect to the care of the
individual.
``(5) When post-stabilization care required to be
covered.--
``(A) When treating physician unable to communicate
request.--If the treating physician or other individual makes
the good faith effort to request authorization under
paragraph (1)(C) but is unable to communicate the request
directly with an authorized person referred to in such
paragraph within 30 minutes after the time of initiating such
effort, then post-stabilization care is required to be
covered under this subsection beginning at the end of such
30-minute period.
``(B) When able to communicate request, and no timely
response.--
``(i) In general.--If the treating physician or other
individual under paragraph (1)(C) is able to communicate the
request within the 30-minute period described in subparagraph
(A), the post-stabilization care requested is required to be
covered under this subsection beginning 30 minutes after the
time when the entity receives the request unless a person
authorized by the entity involved communicates (or makes a
good faith effort to communicate) a denial of the request for
the prior authorization determination within 30 minutes of
the time when the entity receives the request and the
treating physician does not request under clause (ii) to
communicate directly with an authorized physician concerning
the denial.
``(ii) Request for direct physician-to-physician
communication concerning denial.--If a denial of a request is
communicated under clause (i), the treating physician may
request to communicate respecting the denial directly with a
physician who is authorized by the entity to deny or affirm
such a denial.
``(C) When no timely response to request for physician-to-
physician communication.--If a request for physician-to-
physician communication is made under subparagraph (B)(ii),
the post-stabilization care requested is required to be
covered under this subsection beginning 30 minutes after the
time when the entity receives the request from a treating
physician unless a physician, who is authorized by the entity
to reverse or affirm the initial denial of the care,
communicates (or makes a good faith effort to communicate)
directly with the treating physician within such 30-minute
period.
``(D) Disagreements over post-stabilization care.--If,
after a direct physician-to-physician communication under
subparagraph (C), the denial of the request for the post-
stabilization care is not reversed and the treating physician
communicates to the entity involved a disagreement with such
decision, the post-stabilization care requested is required
to be covered under this subsection beginning as follows:
``(i) Delay to allow for prompt arrival of physician
assuming responsibility.--If the issuer communicates that a
physician (designated by the entity) with privileges at the
hospital involved will arrive promptly (as determined under
guidelines) at the emergency department of the hospital in
order to assume responsibility with respect to the treatment
of the enrollee involved, the required coverage of the post-
stabilization care begins after the passage of such time
period as would allow the prompt arrival of such a physician.
``(ii) Other cases.--If the entity does not so communicate,
the required coverage of
[[Page
S5450]]
the post-stabilization care begins immediately.
``(6) No requirement of coverage of post-stabilization care
if alternate plan of treatment.--
``(A) In general.--Coverage of post-stabilization care is
not required under this subsection with respect to an
individual when--
``(i) subject to subparagraph (B), a physician (designated
by the entity involved) and with privileges at the hospital
involved arrives at the emergency department of the hospital
and assumes responsibility with respect to the treatment of
the individual; or
``(ii) the treating physician and the entity agree to
another arrangement with respect to the post-stabilization
care (such as an appropriate transfer of the individual
involved to another facility or an appointment for timely
followup treatment for the individual).
``(B) Special rule where once care initiated.--Required
coverage of requested post-stabilization care shall not end
by reason of subparagraph (A)(i) during an episode of care
(as determined by guidelines) if the treating physician
initiated such care (consistent with a previous paragraph)
before the arrival of a physician described in such
subparagraph.
``(7) Construction.--Nothing in this subsection shall be
construed as--
``(A) preventing a managed care entity from authorizing
coverage of maintenance care or post-stabilization care in
advance or at any time; or
``(B) preventing a treating physician or other individual
described in paragraph (1)(C) and such an entity from
agreeing to modify any of the time periods specified in
paragraphs (5) as it relates to cases involving such persons.
``(c) Information on Access to Emergency Services.--A
managed care entity, to the extent the entity offers health
insurance coverage, shall provide education to enrollees on--
``(1) coverage of emergency services (as defined in
subsection (a)(2)(B)) by the entity in accordance with the
provisions of this section,
``(2) the appropriate use of emergency services, including
use of the 911 telephone system or its local equivalent,
``(3) any cost sharing applicable to emergency services,
``(4) the process and procedures of the plan for obtaining
emergency services, and
``(5) the locations of--
``(A) emergency departments, and
``(B) other settings,
in which participating physicians and hospitals provide
emergency services and post-stabilization care.
``(d) General Definitions.--For purposes of this section:
``(1) Cost sharing.--The term `cost sharing' means any
deductible, coinsurance amount, copayment or other out-of-
pocket payment (other than premiums or enrollment fees) that
a managed care entity issuer imposes on enrollees with
respect to the coverage of benefits.
``(2) Good faith effort.--The term `good faith effort' has
the meaning given such term in guidelines and requires such
appropriate documentation as is specified under such
guidelines.
``(3) Guidelines.--The term `guidelines' means guidelines
established by the Secretary after consultation with an
advisory panel that includes individuals representing
emergency physicians, managed care entities, including at
least one health maintenance organization, hospitals,
employers, the States, and consumers.
``(4) Prior authorization determination.--The term `prior
authorization determination' means, with respect to items and
services for which coverage may be provided by a managed are
entity, a determination (before the provision of the items
and services and as a condition of coverage of the items and
services under the coverage) of whether or not such items and
services will be covered under the coverage.
``(5) Stabilize.--The term `to stabilize' means, with
respect to an emergency medical condition, to provide (in
complying with section 1867 of the Social Security Act) such
medical treatment of the condition as may be necessary to
assure, within reasonable medical probability, that no
material deterioration of the condition is likely to result
from or occur during the transfer of the individual from the
facility.
``(6) Stabilized.--The term `stabilized' means, with
respect to an emergency medical condition, that no material
deterioration of the condition is likely, within reasonable
medical probability, to result from or occur before an
individual can be transferred from the facility, in
compliance with the requirements of section 1867 of the
Social Security Act.
``(7) Treating physician.--The term `treating physician'
includes a treating health care professional who is licensed
under State law to provide emergency services other than
under the supervision of a physician.
``SEC. 1944. OTHER BENEFICIARY PROTECTIONS.
``(a) Protecting Enrollees Against the Insolvency of
Managed Care Entities and Against the Failure of the State to
Pay Such Entities.--Each managed care entity shall provide
that an individual eligible for medical assistance under the
State plan under this title who is enrolled with the entity
may not be held liable--
``(1) for the debts of the managed care entity, in the
event of the medicaid managed care organization's insolvency;
``(2) for services provided to the individual--
``(A) in the event of the medicaid managed care
organization failing to receive payment from the State for
such services; or
``(B) in the event of a health care provider with a
contractual or other arrangement with the medicaid managed
care organization failing to receive payment from the State
or the managed care entity for such services; or
``(3) for the debts of any health care provider with a
contractual or other arrangement with the medicaid managed
care organization to provide services to the individual, in
the event of the insolvency of the health care provider.
``(b) Protection of Beneficiaries Against Balance Billing
Through Subcontractors.--
``(1) In general.--Any contract between a managed care
entity that has an agreement with a State under this title
and another entity under which the entity (or any other
entity pursuant to the contract) provides directly or
indirectly for the provision of services to beneficiaries
under the agreement with the State shall include such
provisions as the Secretary may require in order to assure
that the entity complies with balance billing limitations and
other requirements of this title (such as limitation on
withholding of services) as they would apply to the managed
care entity if such entity provided such services directly
and not through a contract with another entity.
``(2) Application of sanctions for violations.--The
provisions of
Amendments:
Cosponsors:
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
Sponsor:
Summary:
All articles in Senate section
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
(Senate - June 10, 1997)
Text of this article available as:
TXT
PDF
[Pages
S5444-S5464]
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
By Mr. MOYNIHAN (for himself and Mr. Sarbames):
S. 863. A bill to authorize the Government of India to establish a
memorial to honor Mahatma Gandhi in the District of Columbia; to the
Committee on Energy and Natural Resources.
Legislation to Establish Mahatma Gandhi Memorial
Mr. MOYNIHAN. Mr. President, I rise to introduce a bill to authorize
the placement of a statue of Mohandas Karamchand Gandhi --Mahatma
Gandhi--on Federal land across the street from the Indian embassy in
Washington DC. The Government of India has offered a statue of Gandhi
as a gift to the United States. In order to place it on Federal land,
an act of Congress is required. This bill will fulfill just that
purpose, and I thank the Senator from Florida [Mr. Mack] and the
Senator from Maryland, [Mr. Sarbanes] for joining me in this endeavor.
India is currently celebrating the 50th anniversary of its
independence. Authorizing the placement of a statue of Mahatma Gandhi,
often called the father of the Indian nation, would serve as a fitting
tribute to Indian democracy which has survived--in fact, thrived--
despite enormous challenges, and a symbol of the growing strength of
the bonds between our two countries.
It is particularly appropriate that a statue of Mahatma Gandhi be
selected for this purpose. The effects of his non-
[[Page
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violent actions and the philosophy which guided them were not limited
to his country, nor his time. His influence in the United States was
most notably felt in the civil rights movement, but has also infused
all levels of our society.
If I may invade ever so slightly the privacy of the President's
luncheon table, in May 1994, Mr. Clinton had as his guest the
distinguished Prime Minister of India, Mr. P.V. Narasimha Rao, who in
his youth was a follower of Mahatma Gandhi. In a graceful passage,
Prime Minister Rao related how it came to pass that Mahatma Gandhi,
caught up in the struggle for fair treatment to the Indian community in
South Africa, and in consequence in jail, read Thoreau's essay on
``Civil Disobedience'' which confirmed his view that an honest man is
duty-bound to violate unjust laws. He took this view home with him, and
in the end the British raj gave way to an independent Republic of
India. Then Martin Luther King, Jr., repatriated the idea and so began
the great civil rights movement of this century.
Dr. Martin Luther King, Jr., has written of the singular influence
Gandhi's message of nonviolent resistance had on him when he first
learned of it while studying at Crozier Theological Seminary in
Philadelphia. He would later describe that influence in his first book,
``Stride Toward Freedom'':
As I read I became deeply fascinated by [Gandhi's]
philosophy of non-violent resistance . . . as I delved deeper
into the philosophy of Gandhi, my skepticism concerning the
power of love gradually diminished, and I came to see its
potency in the area of social reform . . . prior to reading
Gandhi, I had concluded that the love ethics of Jesus were
only effective in individual relationships . . . but after
reading Gandhi, I saw how utterly mistaken I was.
. . . It was in this Gandhian emphasis on love and non-
violence that I discovered the method for social reform that
I had been seeking for so many months . . . I came to feel
that this was the only morally and practically sound method
open to oppressed people in their struggle for freedom . . .
this principle became the guiding light of our movement.
Christ furnished the spirit and motivation and Gandhi
furnished the method.
Martin Luther King, Jr., believed that Gandhi's philosophy of
nonviolent resistance was the guiding light of the American civil
rights movement. As Dr. King wrote, ``Gandhi furnished the message.'' A
statue of Gandhi, given as a gift from the Government of India, on a
small plot of Federal land along Massachusetts Avenue, in front of the
Indian Embassy, will stand not only as a tribute to the shared values
of the two largest democracies in the world but will also pay tribute
to the lasting influence of Gandhian thought on the United States. An
influence that is so pervasive that when the President and the Prime
Minister of India meet at the White House for lunch, a half-century
after Gandhi's death, it is no surprise that he should be a topic of
conversation.
______
By Mr. CHAFEE (for himself, Mr. Breaux, Mr. Kerrey, and Mr.
Conrad):
S. 864. A bill to amend title XIX of the Social Security Act to
improve the provision of managed care under the Medicaid Program; to
the Committee on Finance.
The Medicaid Managed Care Act of 1997
Mr. CHAFEE. Mr. President, I am pleased today to introduce The
Medicaid Managed Care Act of 1997. This legislation meets two very
important objectives in the Medicaid Program. First, it gives States
the additional flexibility they need to administer the Medicaid Program
by allowing them to enroll Medicaid beneficiaries into managed care
Programs. Second, the bill sets Federal standards for managed care to
ensure that Medicaid patients receive the same quality of care as those
patients who are enrolled in private managed care plans.
Under our legislation, States could require Medicaid patients to
enroll in managed care plans without going through the lengthy and
cumbersome process of applying to the Secretary of Health and Human
Services for a waiver of current Medicaid regulations. In exchange for
this important flexibility, States will have to meet a set of minimum
Federal standards to ensure that Medicaid patients continue to receive
quality care.
For example, States would be required to offer patients a choice of
at least two health plans. Plans would be required to meet certain
standards of access to care, quality, and solvency. These standards are
especially important given recent problems in States that have set up
Medicaid managed care programs under the waiver process. In some
instances, plans have failed to contract with enough providers to serve
the Medicaid population. Some have been permitted to operate under
standards that are lower than commercial insurers are required to meet,
and others have used fraudulent marketing practices to entice Medicaid
patients to sign up with their plans. These actions have resulted in
patients being denied medically necessary services, and have resulted
in States and the Federal Government paying for care that was never
given.
Considering these abuses, why should we allow Medicaid managed care
at all? Because managed care, if implemented correctly, can vastly
improve the quality of health care provided to low-income families. In
today's fee-for-service program, patients face myriad problems. Some
are forced to get care in hospital emergency rooms because they cannot
find a private physician willing or able to accept Medicaid's low
payment rates. Those who do have access to providers often must wait
for hours in clinics which are overcrowded and understaffed. And,
sadly, they often do not have access to primary and preventive care
services which would have prevented them from becoming ill to begin
with.
Medicaid managed care, if done well, provides regular prenatal care
to assure that children are born healthy. These plans provide coverage
for check-ups and immunizations to prevent serious illnesses. And they
give patients a medical home--a provider they know they can go to if
they are sick, or a number to call if they have questions.
Medicaid managed care also has the potential of benefiting our
overall health care system by providing access to primary care
providers rather than forcing patients to make costly and unnecessary
visits to hospital emergency rooms. It gives providers the opportunity
to catch and treat, or prevent, costly health problems.
Mr. President, we have worked very hard to ensure that this
legislation strikes an appropriate balance between the needs of
Medicaid beneficiaries and the managed care companies. I want to thank
Senators Breaux and Kerrey who helped craft this legislation and are
original cosponsors. I also want to thank the many advocacy
organizations for their input and support. And I also want to thank
some of the managed care organizations who worked with us. I am
especially pleased that some of these organizations, such as the HMO
Group which is an alliance of health maintenance organizations have
endorsed this legislation. Their support is critical to the success of
Medicaid managed care.
I ask unanimous consent that the text of the legislation be included
in the Record.
There being no objection, the bill was ordered to be printed in the
Record, as follows:
S. 864
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS; AMENDMENTS TO THE
SOCIAL SECURITY ACT.
(a) Short Title.--This Act may be cited as the ``Medicaid
Managed Care Improvement Act of 1997''.
(b) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents; amendments to the Social
Security Act.
Sec. 2. Improvements in medicaid managed care program.
``Part B--Provisions Relating to Managed Care
``Sec. 1941. Beneficiary choice; enrollment.
``Sec. 1942. Beneficiary access to services generally.
``Sec. 1943. Beneficiary access to emergency care.
``Sec. 1944. Other beneficiary protections.
``Sec. 1945. Assuring quality care.
``Sec. 1946. Protections for providers.
``Sec. 1947. Assuring adequacy of payments to medicaid managed care
organizations and entities.
``Sec. 1948. Fraud and abuse.
``Sec. 1949. Sanctions for noncompliance by managed care entities.
``Sec. 1950. Definitions; miscellaneous provisions.''
[[Page
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Sec. 3. Studies and reports.
Sec. 4. Conforming amendments.
Sec. 5. Effective date; status of waivers.
(c) Amendments to Social Security Act.--Except as otherwise
specifically provided, whenever in this Act an amendment is
expressed in terms of an amendment to or repeal of a section
or other provision, the reference shall be considered to be
made to that section or other provision of the Social
Security Act.
SEC. 2. IMPROVEMENTS IN MEDICAID MANAGED CARE PROGRAM.
Title XIX is amended--
(1) by inserting after the title heading the following:
``Part A--General Provisions''; and
(2) by adding at the end the following new part:
``Part B--Provisions Relating to Managed Care
``SEC. 1941. BENEFICIARY CHOICE; ENROLLMENT.
``(a) State Options for Enrollment of Beneficiaries in
Managed Care Arrangements.--
``(1) In general.--Subject to the succeeding provisions of
this part and notwithstanding paragraphs (1), (10)(B), and
(23)(A) of section 1902(a), a State may require an individual
who is eligible for medical assistance under the State plan
under this title and who is not a special needs individual
(as defined in subsection (e)) to enroll with a managed care
entity (as defined in section 1950(a)(1)) as a condition of
receiving such assistance (and, with respect to assistance
furnished by or under arrangements with such entity, to
receive such assistance through the entity), if the following
provisions are met:
``(A) Entity meets requirements.--The entity meets the
applicable requirements of this part.
``(B) Contract with state.--The entity enters into a
contract with the State to provide services for the benefit
of individuals eligible for benefits under this title under
which prepaid payments to such entity are made on an
actuarially sound basis. Such contract shall specify benefits
the provision (or arrangement) for which the entity is
responsible.
``(C) Choice of coverage.--
``(i) In general.--The State permits an individual to
choose a managed care entity from managed care organizations
and primary care case providers who meet the requirements of
this part but not less than from--
``(I) 2 medicaid managed care organizations,
``(II) a medicaid managed care organization and a primary
care case management provider, or
``(III) a primary care case management provider as long as
an individual may choose between 2 primary care case
managers.
``(ii) State option.--At the option of the State, a State
shall be considered to meet the requirements of clause (i) in
the case of an individual residing in a rural area, if the
State--
``(I) requires the individual to enroll with a medicaid
managed care organization or primary care case management
provider if such organization or entity permits the
individual to receive such assistance through not less than 2
physicians or case managers (to the extent that at least 2
physicians or case managers are available to provide such
assistance in the area), and
``(II) permits the individual to obtain such assistance
from any other provider in appropriate circumstances (as
established by the State under regulations of the Secretary).
``(D) Changes in enrollment.--The State provides the
individual with the opportunity to change enrollment among
managed care entities once annually and notifies the
individual of such opportunity not later than 60 days prior
to the first date on which the individual may change
enrollment, permits individuals to change their enrollment
for cause at any time and without cause at least every 12
months, and allows individuals to disenroll without cause
within 90 days of notification of enrollment.
``(E) Enrollment priorities.--The State establishes a
method for establishing enrollment priorities in the case of
a managed care entity that does not have sufficient capacity
to enroll all such individuals seeking enrollment under which
individuals already enrolled with the entity are given
priority in continuing enrollment with the entity.
``(F) Default enrollment process.--The State establishes a
default enrollment process which meets the requirements
described in paragraph (2) and under which any such
individual who does not enroll with a managed care entity
during the enrollment period specified by the State shall be
enrolled by the State with such an entity in accordance with
such process.
``(G) Sanctions.--The State establishes the sanctions
provided for in section 1949.
``(2) Default enrollment process requirements.--The default
enrollment process established by a State under paragraph
(1)(F)--
``(A) shall provide that the State may not enroll
individuals with a managed care entity which is not in
compliance with the applicable requirements of this part;
``(B) shall provide (consistent with subparagraph (A)) for
enrollment of such an individual with a medicaid managed care
organization--
``(i) first, that maintains existing provider-individual
relationships or that has entered into contracts with
providers (such as Federally qualified health centers, rural
health clinics, hospitals that qualify for disproportionate
share hospital payments under section 1886(d)(5)(F), and
hospitals described in section 1886(d)(1)(B)(iii)) that have
traditionally served beneficiaries under this title, and
``(ii) lastly, if there is no provider described in clause
(i), in a manner that provides for an equitable distribution
of individuals among all qualified managed care entities
available to enroll individuals through such default
enrollment process, consistent with the enrollment capacities
of such entities;
``(C) shall permit and assist an individual enrolled with
an entity under such process to change such enrollment to
another managed care entity during a period (of at least 90
days) after the effective date of the enrollment; and
``(D) may provide for consideration of factors such as
quality, geographic proximity, continuity of providers, and
capacity of the plan when conducting such process.
``(b) Reenrollment of Individuals Who Regain Eligibility.--
``(1) In general.--If an individual eligible for medical
assistance under a State plan under this title and enrolled
with a managed care entity with a contract under subsection
(a)(1)(B) ceases to be eligible for such assistance for a
period of not greater than 2 months, the State may provide
for the automatic reenrollment of the individual with the
entity as of the first day of the month in which the
individual is again eligible for such assistance, and may
consider factors such as quality, geographic proximity,
continuity of providers, and capacity of the plan when
conducting such reenrollment.
``(2) Conditions.--Paragraph (1) shall only apply if--
``(A) the month for which the individual is to be
reenrolled occurs during the enrollment period covered by the
individual's original enrollment with the managed care
entity;
``(B) the managed care entity continues to have a contract
with the State agency under subsection (a)(1)(B) as of the
first day of such month; and
``(C) the managed care entity complies with the applicable
requirements of this part.
``(3) Notice of reenrollment.--The State shall provide
timely notice to a managed care entity of any reenrollment of
an individual under this subsection.
``(c) State Option of Minimum Enrollment Period.--
``(1) In general.--In the case of an individual who is
enrolled with a managed care entity under this part and who
would (but for this subsection) lose eligibility for benefits
under this title before the end of the minimum enrollment
period (defined in paragraph (2)), the State plan under this
title may provide, notwithstanding any other provision of
this title, that the individual shall be deemed to continue
to be eligible for such benefits until the end of such
minimum period, but, except for benefits furnished under
section 1902(a)(23)(B), only with respect to such benefits
provided to the individual as an enrollee of such entity.
``(2) Minimum enrollment period defined.--For purposes of
paragraph (1), the term `minimum enrollment period' means,
with respect to an individual's enrollment with an entity
under a State plan, a period, established by the State, of
not more than 6 months beginning on the date the individual's
enrollment with the entity becomes effective, except that a
State may extend such period for up to a total of 12 months
in the case of an individual's enrollment with a managed care
entity (as defined in section 1950(a)(1)) so long as such
extension is done uniformly for all individuals enrolled with
all such entities.
``(d) Other Enrollment-Related Provisions.--
``(1) Nondiscrimination.--A managed care entity may not
discriminate on the basis of health status or anticipated
need for services in the enrollment, reenrollment, or
disenrollment of individuals eligible to receive medical
assistance under a State plan under this title or by
discouraging enrollment (except as permitted by this section)
by eligible individuals.
``(2) Termination of enrollment.--
``(A) In general.--The State, enrollment broker, and
managed care entity (if any) shall permit an individual
eligible for medical assistance under the State plan under
this title who is enrolled with the entity to terminate such
enrollment for cause at any time, and without cause during
the 90-day period beginning on the date the individual
receives notice of enrollment and at least every 12 months
thereafter, and shall notify each such individual of the
opportunity to terminate enrollment under these conditions.
``(B) Fraudulent inducement or coercion as grounds for
cause.--For purposes of subparagraph (A), an individual
terminating enrollment with a managed care entity on the
grounds that the enrollment was based on fraudulent
inducement or was obtained through coercion or pursuant to
the imposition against the managed care entity of the
sanction described in section 1949(b)(3) shall be considered
to terminate such enrollment for cause.
``(C) Notice of termination.--
``(i) Notice to state.--
``(I) By individuals.--Each individual terminating
enrollment with a managed care entity under subparagraph (A)
shall do so by
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providing notice of the termination to an office of the State
agency administering the State plan under this title, the
State or local welfare agency, or an office of a managed care
entity.
``(II) By organizations.--Any managed care entity which
receives notice of an individual's termination of enrollment
with such entity through receipt of such notice at an office
of a managed care entity shall provide timely notice of the
termination to the State agency administering the State plan
under this title.
``(ii) Notice to plan.--The State agency administering the
State plan under this title or the State or local welfare
agency which receives notice of an individual's termination
of enrollment with a managed care entity under clause (i)
shall provide timely notice of the termination to such
entity.
``(3) Provision of information.--
``(A) In general.--Each State, enrollment broker, or
managed care organization shall provide all enrollment
notices and informational and instructional materials in a
manner and form which may be easily understood by enrollees
of the entity who are eligible for medical assistance under
the State plan under this title, including enrollees and
potential enrollees who are blind, deaf, disabled, or cannot
read or understand the English language.
``(B) Information to health care providers, enrollees, and
potential enrollees.--Each medicaid managed care organization
shall--
``(i) upon request, make the information described in
section 1945(e)(1)(A)available to enrollees and potential
enrollees in the organization's service area; and
``(ii) provide to enrollees and potential enrollees
information regarding all items and services that are
available to enrollees under the contract between the State
and the organization that are covered either directly or
through a method of referral and prior authorization.
``(e) Special Needs Individuals Described.--In this part,
the term `special needs individual' means any of the
following individuals:
``(1) Special needs child.--An individual who is under 19
years of age who--
``(A) is eligible for supplemental security income under
title XVI;
``(B) is described under section 501(a)(1)(D);
``(C) is a child described in section 1902(e)(3);
``(D) is receiving services under a program under part B or
part E of title IV; or
``(E) is not described in any preceding subparagraph but is
otherwise considered a child with special health care needs
who is adopted, in foster care, or otherwise in an out-of-
home placement.
``(2) Homeless individuals.--An individual who is homeless
(without regard to whether the individual is a member of a
family), including--
``(A) an individual whose primary residence during the
night is a supervised public or private facility that
provides temporary living accommodations; or
``(B) an individual who is a resident in transitional
housing.
``(3) Migrant agricultural workers.--A migratory
agricultural worker or a seasonal agricultural worker (as
such terms are defined in section 330(g)(3) of the Public
Health Service Act), or the spouse or dependent of such a
worker.
``(4) Indians.--An Indian (as defined in section 4(c) of
the Indian Health Care Improvement Act (25 U.S.C. 1603(c))).
``(5) Medicare beneficiaries.--A qualified medicare
beneficiary (as defined in section 1905(p)(1)) or an
individual otherwise eligible for benefits under title XVIII.
``(6) Disabled individuals.--Individuals who are disabled
(as determined under section 1614(a)(3)).
``(7) Persons with aids or hiv infection.--An individual
with acquired immune deficiency syndrome (AIDS) or who has
been determined to be infected with the HIV virus.
``SEC. 1942. BENEFICIARY ACCESS TO SERVICES GENERALLY.
``(a) Access to Services.--
``(1) In general.--Each managed care entity shall provide
or arrange for the provision of all medically necessary
medical assistance under this title which is specified in the
contract entered into between such entity and the State under
section 1941(a)(1)(B) for enrollees who are eligible for
medical assistance under the State plan under this title.
``(2) Primary-care-provider-to-enrollee ratio and maximum
travel time.--Each such entity shall assure adequate access
to primary care services by meeting standards, established by
the Secretary, relating to the maximum ratio of enrollees
under this title to full-time-equivalent primary care
providers available to serve such enrollees and to maximum
travel time for such enrollees to access such providers. The
Secretary may permit such a maximum ratio to vary depending
on the area and population served. Such standards shall be
based on standards commonly applied in the commercial market,
commonly used in accreditation of managed care organizations,
and standards used in the approval of waiver applications
under section 1115, and shall be consistent with the
requirements under section 1876(c)(4)(A).
``(b) Obstetrical and Gynecological Care.--
``(1) In general.--A managed care entity may not require
prior authorization by the individual's primary care provider
or otherwise restrict the individual's access to
gynecological and obstetrical care provided by a
participating provider who specializes in obstetrics and
gynecology to the extent such care is otherwise covered, and
may treat the ordering of other obstetrical and gynecological
care by such a participating provider as the prior
authorization of the primary care provider with respect to
such care under the coverage.
``(2) Construction.--Nothing in paragraph (1)(B)(ii) shall
waive any requirements of coverage relating to medical
necessity or appropriateness with respect to coverage of
gynecological care so ordered.
``(c) Specialty Care.--
``(1) Referral to specialty care for enrollees requiring
treatment by specialists.--
``(A) In general.--In the case of an enrollee under a
managed care entity and who has a condition or disease of
sufficient seriousness and complexity to require treatment by
a specialist, the entity shall make or provide for a referral
to a specialist who is available and accessible to provide
the treatment for such condition or disease.
``(B) Specialist defined.--For purposes of this subsection,
the term `specialist' means, with respect to a condition, a
health care practitioner, facility, or center (such as a
center of excellence) that has adequate expertise through
appropriate training and experience (including, in the case
of a child, an appropriate pediatric specialist) to provide
high quality care in treating the condition.
``(C) Care under referral.--Care provided pursuant to such
referral under subparagraph (A) shall be--
``(i) pursuant to a treatment plan (if any) developed by
the specialist and approved by the entity, in consultation
with the designated primary care provider or specialist and
the enrollee (or the enrollee's designee), and
``(ii) in accordance with applicable quality assurance and
utilization review standards of the entity.
Nothing in this subsection shall be construed as preventing
such a treatment plan for an enrollee from requiring a
specialist to provide the primary care provider with regular
updates on the specialty care provided, as well as all
necessary medical information.
``(D) Referrals to participating providers.--An entity is
not required under subparagraph (A) to provide for a referral
to a specialist that is not a participating provider, unless
the entity does not have an appropriate specialist that is
available and accessible to treat the enrollee's condition
and that is a participating provider with respect to such
treatment.
``(E) Treatment of nonparticipating providers.--If an
entity refers an enrollee to a nonparticipating specialist,
services provided pursuant to the approved treatment plan
shall be provided at no additional cost to the enrollee
beyond what the enrollee would otherwise pay for services
received by such a specialist that is a participating
provider.
``(2) Specialists as primary care providers.--
``(A) In general.--A managed care entity shall have a
procedure by which a new enrollee upon enrollment, or an
enrollee upon diagnosis, with an ongoing special condition
(as defined in subparagraph (C)) may receive a referral to a
specialist for such condition who shall be responsible for
and capable of providing and coordinating the enrollee's
primary and specialty care. If such an enrollee's care would
most appropriately be coordinated by such a specialist, the
entity shall refer the enrollee to such specialist.
``(B) Treatment as primary care provider.--Such specialist
shall be permitted to treat the enrollee without a referral
from the enrollee's primary care provider and may authorize
such referrals, procedures, tests, and other medical services
as the enrollee's primary care provider would otherwise be
permitted to provide or authorize, subject to the terms of
the treatment plan (referred to in paragraph (1)(C)(i)).
``(C) Ongoing special condition defined.--In this
paragraph, the term `special condition' means a physical and
mental condition or disease that--
``(i) is life-threatening, degenerative, or disabling, and
``(ii) requires specialized medical care over a prolonged
period of time.
``(D) Terms of referral.--The provisions of subparagraphs
(C) through (E) of paragraph (1) shall apply with respect to
referrals under subparagraph (A) of this paragraph in the
same manner as they apply to referrals under paragraph
(1)(A).
``(3) Standing referrals.--
``(A) In general.--A managed care entity shall have a
procedure by which an enrollee who has a condition that
requires ongoing care from a specialist may receive a
standing referral to such specialist for treatment of such
condition. If the issuer, or the primary care provider in
consultation with the medical director of the entity and the
specialist (if any), determines that such a standing referral
is appropriate, the entity shall make such a referral to such
a specialist.
``(B) Terms of referral.--The provisions of subparagraphs
(C) through (E) of paragraph (1) shall apply with respect to
referrals under subparagraph (A) of this paragraph in the
same manner as they apply to referrals under paragraph
(1)(A).
``(d) Timely Delivery of Services.--Each managed care
entity shall respond to requests from enrollees for the
delivery of medical assistance in a manner which--
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``(1) makes such assistance--
``(A) available and accessible to each such individual,
within the area served by the entity, with reasonable
promptness and in a manner which assures continuity; and
``(B) when medically necessary, available and accessible 24
hours a day and 7 days a week; and
``(2) with respect to assistance provided to such an
individual other than through the entity, or without prior
authorization, in the case of a primary care case management
provider, provides for reimbursement to the individual (if
applicable under the contract between the State and the
entity) if--
``(A) the services were medically necessary and immediately
required because of an unforeseen illness, injury, or
condition and meet the requirements of section 1943; and
``(B) it was not reasonable given the circumstances to
obtain the services through the entity, or, in the case of a
primary care case management provider, with prior
authorization.
``(e) Internal Grievance Procedure.--Each medicaid managed
care organization shall establish an internal grievance
procedure under which an enrollee who is eligible for medical
assistance under the State plan under this title, or a
provider on behalf of such an enrollee, may challenge the
denial of coverage of or payment for such assistance.
``(f) Information on Benefit Carve Outs.--Each managed care
entity shall inform each enrollee, in a written and prominent
manner, of any benefits to which the enrollee may be entitled
to medical assistance under this title but which are not made
available to the enrollee through the entity. Such
information shall include information on where and how such
enrollees may access benefits not made available to the
enrollee through the entity.
``(g) Due Process Requirements for Managed Care Entities.--
``(1) Denial of or unreasonable delay in determining
coverage as grounds for hearing.--If a managed care entity
(or entity acting an agreement with a managed care entity)--
``(A) denies coverage of or payment for medical assistance
with respect to an enrollee who is eligible for such
assistance under the State plan under this title; or
``(B) fails to make any eligibility or coverage
determination sought by an enrollee or, in the case of a
medicaid managed care organization, by a participating health
care provider or enrollee, in a timely manner, depending upon
the urgency of the situation,
the enrollee or the health care provider furnishing such
assistance to the enrollee (as applicable) may obtain a fair
hearing before, and shall be provided a timely decision by,
the State agency administering the State plan under this
title in accordance with section 1902(a)(3). Such decisions
shall be rendered as soon as possible in accordance with the
medical exigencies of the cases, and in no event later than
72 hours in the case of hearings on decisions regarding
urgent care and 5 days in the case of all other hearings.
``(2) Completion of internal grievance procedure.--Nothing
in this subsection shall require completion of an internal
grievance procedure if the procedure does not provide for
timely review of health needs considered by the enrollee's
health care provider to be of an urgent nature or is not
otherwise consistent with the requirements for such
procedures under section 1876(c).
``(h) Demonstration of Adequate Capacity and Services.--
``(1) In general.--Subject to paragraph (3), each medicaid
managed care organization shall provide the State and the
Secretary with adequate assurances (as determined by the
Secretary) that the organization, with respect to a service
area--
``(A) has the capacity to serve the expected enrollment in
such service area;
``(B) offers an appropriate range of services for the
population expected to be enrolled in such service area,
including transportation services and translation services
consisting of the principal languages spoken in the service
area;
``(C) maintains a sufficient number, mix, and geographic
distribution of providers of services included in the
contract with the State to ensure that services are available
to individuals receiving medical assistance and enrolled in
the organization to the same extent that such services are
available to individuals enrolled in the organization who are
not recipients of medical assistance under the State plan
under this title;
``(D) maintains extended hours of operation with respect to
primary care services that are beyond those maintained during
a normal business day;
``(E) provides preventive and primary care services in
locations that are readily accessible to members of the
community;
``(F) provides information concerning educational, social,
health, and nutritional services offered by other programs
for which enrollees may be eligible; and
``(G) complies with such other requirements relating to
access to care as the Secretary or the State may impose.
``(2) Proof of adequate primary care capacity and
services.--Subject to paragraph (3), a medicaid managed care
organization that contracts with a reasonable number of
primary care providers (as determined by the Secretary) and
whose primary care membership includes a reasonable number
(as so determined) of the following providers will be deemed
to have satisfied the requirements of paragraph (1):
``(A) Rural health clinics, as defined in section
1905(l)(1).
``(B) Federally-qualified health centers, as defined in
section 1905(l)(2)(B).
``(C) Clinics which are eligible to receive payment for
services provided under title X of the Public Health Service
Act.
``(3) Sufficient providers of specialized services.--
Notwithstanding paragraphs (1) and (2), a medicaid managed
care organization may not be considered to have satisfied the
requirements of paragraph (1) if the organization does not
have a sufficient number (as determined by the Secretary) of
providers of specialized services, including perinatal and
pediatric specialty care, to ensure that such services are
available and accessible.
``(i) Compliance With Certain Maternity and Mental Health
Requirements.--Each medicaid managed care organization shall
comply with the requirements of subpart 2 of part A of title
XXVII of the Public Health Service Act insofar as such
requirements apply with respect to a health insurance issuer
that offers group health insurance coverage.
``(j) Treatment of Children With Special Health Care
Needs.--
``(1) In general.--In the case of an enrollee of a managed
care entity who is a child described in section 1941(e)(1) or
who has special health care needs (as defined in paragraph
(3))--
``(A) if any medical assistance specified in the contract
with the State is identified in a treatment plan prepared for
the enrollee by a program described in subsection (c)(1) or
paragraph (3), the managed care entity shall provide (or
arrange to be provided) such assistance in accordance with
the treatment plan either--
``(i) by referring the enrollee to a pediatric health care
provider who is trained and experienced in the provision of
such assistance and who has a contract with the managed care
entity to provide such assistance; or
``(ii) if appropriate services are not available through
the managed care entity, permitting such enrollee to seek
appropriate specialty services from pediatric health care
providers outside of or apart from the managed care entity;
and
``(B) the managed care entity shall require each health
care provider with whom the managed care entity has entered
into an agreement to provide medical assistance to enrollees
to furnish the medical assistance specified in such
enrollee's treatment plan to the extent the health care
provider is able to carry out such treatment plan.
``(2) Prior authorization.--An enrollee referred for
treatment under paragraph (1)(A)(i), or permitted to seek
treatment outside of or apart from the managed care entity
under paragraph (1)(A)(ii) shall be deemed to have obtained
any prior authorization required by the entity.
``(3) Child with special health care needs.--For purposes
of paragraph (1), a child has special health care needs if
the child is receiving services under--
``(A) a program administered under part B or part H of the
Individuals with Disabilities Education Act; or
``(B) any other program for children with special health
care needs identified by the Secretary.
``SEC. 1943. BENEFICIARY ACCESS TO EMERGENCY CARE.
``(a) Prohibition of Certain Restrictions on Coverage of
Emergency Services.--
``(1) In general.--If a managed care entity provides any
benefits under a State plan with respect to emergency
services (as defined in paragraph (2)(B)), the entity shall
cover emergency services furnished to an enrollee--
``(A) without the need for any prior authorization
determination,
``(B) subject to paragraph (3), whether or not the
physician or provider furnishing such services is a
participating physician or provider with respect to such
services, and
``(C) subject to paragraph (3), without regard to any other
term or condition of such coverage (other than an exclusion
of benefits).
``(2) Emergency services; emergency medical condition.--For
purposes of this section--
``(A) Emergency medical condition based on prudent
layperson.--The term `emergency medical condition' means a
medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a
prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of
immediate medical attention to result in--
``(i) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy,
``(ii) serious impairment to bodily functions, or
``(iii) serious dysfunction of any bodily organ or part.
``(B) Emergency services.--The term `emergency services'
means--
``(i) a medical screening examination (as required under
section 1867) that is within the capability of the emergency
department of a hospital, including ancillary services
routinely available to the emergency department, to evaluate
an emergency medical condition (as defined in subparagraph
(A)), and
``(ii) within the capabilities of the staff and facilities
available at the hospital, such further medical examination
and treatment as
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are required under section 1867 to stabilize the patient.
``(C) Trauma and burn centers.--The provisions of clause
(ii) of subparagraph (B) apply to a trauma or burn center, in
a hospital, that--
``(i) is designated by the State, a regional authority of
the State, or by the designee of the State, or
``(ii) is in a State that has not made such designations
and meets medically recognized national standards.
``(3) Application of network restriction permitted in
certain cases.--
``(A) In general.--Except as provided in subparagraph (B),
if a managed care entity in relation to benefits provided
under this title denies, limits, or otherwise differentiates
in benefits or payment for benefits other than emergency
services on the basis that the physician or provider of such
services is a nonparticipating physician or provider, the
entity may deny, limit, or differentiate in coverage or
payment for emergency services on such basis.
``(B) Network restrictions not permitted in certain
exceptional cases.--The denial or limitation of, or
differentiation in, coverage or payment of benefits for
emergency services under subparagraph (A) shall not apply in
the following cases:
``(i) Circumstances beyond control of enrollee.--The
enrollee is unable to go to a participating hospital for such
services due to circumstances beyond the control of the
enrollee (as determined consistent with guidelines and
subparagraph (C)).
``(ii) Likelihood of an adverse health consequence based on
layperson's judgment.--A prudent layperson possessing an
average knowledge of health and medicine could reasonably
believe that, under the circumstances and consistent with
guidelines, the time required to go to a participating
hospital for such services could result in any of the adverse
health consequences described in a clause of subsection
(a)(2)(A).
``(iii) Physician referral.--A participating physician or
other person authorized by the plan refers the enrollee to an
emergency department of a hospital and does not specify an
emergency department of a hospital that is a participating
hospital with respect to such services.
``(C) Application of `beyond control' standards.--For
purposes of applying subparagraph (B)(i), receipt of
emergency services from a nonparticipating hospital shall be
treated under the guidelines as being `due to circumstances
beyond the control of the enrollee' if any of the following
conditions are met:
``(i) Unconscious.--The enrollee was unconscious or in an
otherwise altered mental state at the time of initiation of
the services.
``(ii) Ambulance delivery.--The enrollee was transported by
an ambulance or other emergency vehicle directed by a person
other than the enrollee to the nonparticipating hospital in
which the services were provided.
``(iii) Natural disaster.--A natural disaster or civil
disturbance prevented the enrollee from presenting to a
participating hospital for the provision of such services.
``(iv) No good faith effort to inform of change in
participation during a contract year.--The status of the
hospital changed from a participating hospital to a
nonparticipating hospital with respect to emergency services
during a contract year and the entity failed to make a good
faith effort to notify the enrollee involved of such change.
``(v) Other conditions.--There were other factors (such as
those identified in guidelines) that prevented the enrollee
from controlling selection of the hospital in which the
services were provided.
``(b) Assuring Coordinated Coverage of Maintenance Care and
Post-Stabilization Care.--
``(1) In general.--In the case of an individual who is
enrolled with a managed care entity and who has received
emergency services pursuant to a screening evaluation
conducted (or supervised) by a treating physician at a
hospital that is a nonparticipating provider with respect to
emergency services, if--
``(A) pursuant to such evaluation, the physician identifies
post-stabilization care (as defined in paragraph (3)(B)) that
is required by the enrollee,
``(B) the coverage through the entity under this title
provides benefits with respect to the care so identified and
the coverage requires (but for this subsection) an
affirmative prior authorization determination as a condition
of coverage of such care, and
``(C) the treating physician (or another individual acting
on behalf of such physician) initiates, not later than 30
minutes after the time the treating physician determines that
the condition of the enrollee is stabilized, a good faith
effort to contact a physician or other person authorized by
the entity (by telephone or other means) to obtain an
affirmative prior authorization determination with respect to
the care,
then, without regard to terms and conditions specified in
paragraph (2) the entity shall cover maintenance care (as
defined in paragraph (3)(A)) furnished to the enrollee during
the period specified in paragraph (4) and shall cover post-
stabilization care furnished to the enrollee during the
period beginning under paragraph (5) and ending under
paragraph (6).
``(2) Terms and conditions waived.--The terms and
conditions (of coverage) described in this paragraph that are
waived under paragraph (1) are as follows:
``(A) The need for any prior authorization determination.
``(B) Any limitation on coverage based on whether or not
the physician or provider furnishing the care is a
participating physician or provider with respect to such
care.
``(C) Any other term or condition of the coverage (other
than an exclusion of benefits and other than a requirement
relating to medical necessity for coverage of benefits).
``(3) Maintenance care and post-stabilization care
defined.--In this subsection:
``(A) Maintenance care.--The term `maintenance care' means,
with respect to an individual who is stabilized after
provision of emergency services, medically necessary items
and services (other than emergency services) that are
required by the individual to ensure that the individual
remains stabilized during the period described in paragraph
(4).
``(B) Post-stabilization care.--The term `post-
stabilization care' means, with respect to an individual who
is determined to be stable pursuant to a medical screening
examination or who is stabilized after provision of emergency
services, medically necessary items and services (other than
emergency services and other than maintenance care) that are
required by the individual.
``(4) Period of required coverage of maintenance care.--The
period of required coverage of maintenance care of an
individual under this subsection begins at the time of the
request (or the initiation of the good faith effort to make
the request) under paragraph (1)(C) and ends when--
``(A) the individual is discharged from the hospital;
``(B) a physician (designated by the managed care entity
involved) and with privileges at the hospital involved
arrives at the emergency department of the hospital and
assumes responsibility with respect to the treatment of the
individual; or
``(C) the treating physician and the entity agree to
another arrangement with respect to the care of the
individual.
``(5) When post-stabilization care required to be
covered.--
``(A) When treating physician unable to communicate
request.--If the treating physician or other individual makes
the good faith effort to request authorization under
paragraph (1)(C) but is unable to communicate the request
directly with an authorized person referred to in such
paragraph within 30 minutes after the time of initiating such
effort, then post-stabilization care is required to be
covered under this subsection beginning at the end of such
30-minute period.
``(B) When able to communicate request, and no timely
response.--
``(i) In general.--If the treating physician or other
individual under paragraph (1)(C) is able to communicate the
request within the 30-minute period described in subparagraph
(A), the post-stabilization care requested is required to be
covered under this subsection beginning 30 minutes after the
time when the entity receives the request unless a person
authorized by the entity involved communicates (or makes a
good faith effort to communicate) a denial of the request for
the prior authorization determination within 30 minutes of
the time when the entity receives the request and the
treating physician does not request under clause (ii) to
communicate directly with an authorized physician concerning
the denial.
``(ii) Request for direct physician-to-physician
communication concerning denial.--If a denial of a request is
communicated under clause (i), the treating physician may
request to communicate respecting the denial directly with a
physician who is authorized by the entity to deny or affirm
such a denial.
``(C) When no timely response to request for physician-to-
physician communication.--If a request for physician-to-
physician communication is made under subparagraph (B)(ii),
the post-stabilization care requested is required to be
covered under this subsection beginning 30 minutes after the
time when the entity receives the request from a treating
physician unless a physician, who is authorized by the entity
to reverse or affirm the initial denial of the care,
communicates (or makes a good faith effort to communicate)
directly with the treating physician within such 30-minute
period.
``(D) Disagreements over post-stabilization care.--If,
after a direct physician-to-physician communication under
subparagraph (C), the denial of the request for the post-
stabilization care is not reversed and the treating physician
communicates to the entity involved a disagreement with such
decision, the post-stabilization care requested is required
to be covered under this subsection beginning as follows:
``(i) Delay to allow for prompt arrival of physician
assuming responsibility.--If the issuer communicates that a
physician (designated by the entity) with privileges at the
hospital involved will arrive promptly (as determined under
guidelines) at the emergency department of the hospital in
order to assume responsibility with respect to the treatment
of the enrollee involved, the required coverage of the post-
stabilization care begins after the passage of such time
period as would allow the prompt arrival of such a physician.
``(ii) Other cases.--If the entity does not so communicate,
the required coverage of
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the post-stabilization care begins immediately.
``(6) No requirement of coverage of post-stabilization care
if alternate plan of treatment.--
``(A) In general.--Coverage of post-stabilization care is
not required under this subsection with respect to an
individual when--
``(i) subject to subparagraph (B), a physician (designated
by the entity involved) and with privileges at the hospital
involved arrives at the emergency department of the hospital
and assumes responsibility with respect to the treatment of
the individual; or
``(ii) the treating physician and the entity agree to
another arrangement with respect to the post-stabilization
care (such as an appropriate transfer of the individual
involved to another facility or an appointment for timely
followup treatment for the individual).
``(B) Special rule where once care initiated.--Required
coverage of requested post-stabilization care shall not end
by reason of subparagraph (A)(i) during an episode of care
(as determined by guidelines) if the treating physician
initiated such care (consistent with a previous paragraph)
before the arrival of a physician described in such
subparagraph.
``(7) Construction.--Nothing in this subsection shall be
construed as--
``(A) preventing a managed care entity from authorizing
coverage of maintenance care or post-stabilization care in
advance or at any time; or
``(B) preventing a treating physician or other individual
described in paragraph (1)(C) and such an entity from
agreeing to modify any of the time periods specified in
paragraphs (5) as it relates to cases involving such persons.
``(c) Information on Access to Emergency Services.--A
managed care entity, to the extent the entity offers health
insurance coverage, shall provide education to enrollees on--
``(1) coverage of emergency services (as defined in
subsection (a)(2)(B)) by the entity in accordance with the
provisions of this section,
``(2) the appropriate use of emergency services, including
use of the 911 telephone system or its local equivalent,
``(3) any cost sharing applicable to emergency services,
``(4) the process and procedures of the plan for obtaining
emergency services, and
``(5) the locations of--
``(A) emergency departments, and
``(B) other settings,
in which participating physicians and hospitals provide
emergency services and post-stabilization care.
``(d) General Definitions.--For purposes of this section:
``(1) Cost sharing.--The term `cost sharing' means any
deductible, coinsurance amount, copayment or other out-of-
pocket payment (other than premiums or enrollment fees) that
a managed care entity issuer imposes on enrollees with
respect to the coverage of benefits.
``(2) Good faith effort.--The term `good faith effort' has
the meaning given such term in guidelines and requires such
appropriate documentation as is specified under such
guidelines.
``(3) Guidelines.--The term `guidelines' means guidelines
established by the Secretary after consultation with an
advisory panel that includes individuals representing
emergency physicians, managed care entities, including at
least one health maintenance organization, hospitals,
employers, the States, and consumers.
``(4) Prior authorization determination.--The term `prior
authorization determination' means, with respect to items and
services for which coverage may be provided by a managed are
entity, a determination (before the provision of the items
and services and as a condition of coverage of the items and
services under the coverage) of whether or not such items and
services will be covered under the coverage.
``(5) Stabilize.--The term `to stabilize' means, with
respect to an emergency medical condition, to provide (in
complying with section 1867 of the Social Security Act) such
medical treatment of the condition as may be necessary to
assure, within reasonable medical probability, that no
material deterioration of the condition is likely to result
from or occur during the transfer of the individual from the
facility.
``(6) Stabilized.--The term `stabilized' means, with
respect to an emergency medical condition, that no material
deterioration of the condition is likely, within reasonable
medical probability, to result from or occur before an
individual can be transferred from the facility, in
compliance with the requirements of section 1867 of the
Social Security Act.
``(7) Treating physician.--The term `treating physician'
includes a treating health care professional who is licensed
under State law to provide emergency services other than
under the supervision of a physician.
``SEC. 1944. OTHER BENEFICIARY PROTECTIONS.
``(a) Protecting Enrollees Against the Insolvency of
Managed Care Entities and Against the Failure of the State to
Pay Such Entities.--Each managed care entity shall provide
that an individual eligible for medical assistance under the
State plan under this title who is enrolled with the entity
may not be held liable--
``(1) for the debts of the managed care entity, in the
event of the medicaid managed care organization's insolvency;
``(2) for services provided to the individual--
``(A) in the event of the medicaid managed care
organization failing to receive payment from the State for
such services; or
``(B) in the event of a health care provider with a
contractual or other arrangement with the medicaid managed
care organization failing to receive payment from the State
or the managed care entity for such services; or
``(3) for the debts of any health care provider with a
contractual or other arrangement with the medicaid managed
care organization to provide services to the individual, in
the event of the insolvency of the health care provider.
``(b) Protection of Beneficiaries Against Balance Billing
Through Subcontractors.--
``(1) In general.--Any contract between a managed care
entity that has an agreement with a State under this title
and another entity under which the entity (or any other
entity pursuant to the contract) provides directly or
indirectly for the provision of services to beneficiaries
under the agreement with the State shall include such
provisions as the Secretary may require in order to assure
that the entity complies with balance billing limitations and
other requirements of this title (such as limitation on
withholding of services) as they would apply to the managed
care entity if such entity provided such services directly
and not through a contract with another entity.
``(2) Application of sanctions for violations.--The
provisions of section 11
Major Actions:
All articles in Senate section
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
(Senate - June 10, 1997)
Text of this article available as:
TXT
PDF
[Pages
S5444-S5464]
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
By Mr. MOYNIHAN (for himself and Mr. Sarbames):
S. 863. A bill to authorize the Government of India to establish a
memorial to honor Mahatma Gandhi in the District of Columbia; to the
Committee on Energy and Natural Resources.
Legislation to Establish Mahatma Gandhi Memorial
Mr. MOYNIHAN. Mr. President, I rise to introduce a bill to authorize
the placement of a statue of Mohandas Karamchand Gandhi --Mahatma
Gandhi--on Federal land across the street from the Indian embassy in
Washington DC. The Government of India has offered a statue of Gandhi
as a gift to the United States. In order to place it on Federal land,
an act of Congress is required. This bill will fulfill just that
purpose, and I thank the Senator from Florida [Mr. Mack] and the
Senator from Maryland, [Mr. Sarbanes] for joining me in this endeavor.
India is currently celebrating the 50th anniversary of its
independence. Authorizing the placement of a statue of Mahatma Gandhi,
often called the father of the Indian nation, would serve as a fitting
tribute to Indian democracy which has survived--in fact, thrived--
despite enormous challenges, and a symbol of the growing strength of
the bonds between our two countries.
It is particularly appropriate that a statue of Mahatma Gandhi be
selected for this purpose. The effects of his non-
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violent actions and the philosophy which guided them were not limited
to his country, nor his time. His influence in the United States was
most notably felt in the civil rights movement, but has also infused
all levels of our society.
If I may invade ever so slightly the privacy of the President's
luncheon table, in May 1994, Mr. Clinton had as his guest the
distinguished Prime Minister of India, Mr. P.V. Narasimha Rao, who in
his youth was a follower of Mahatma Gandhi. In a graceful passage,
Prime Minister Rao related how it came to pass that Mahatma Gandhi,
caught up in the struggle for fair treatment to the Indian community in
South Africa, and in consequence in jail, read Thoreau's essay on
``Civil Disobedience'' which confirmed his view that an honest man is
duty-bound to violate unjust laws. He took this view home with him, and
in the end the British raj gave way to an independent Republic of
India. Then Martin Luther King, Jr., repatriated the idea and so began
the great civil rights movement of this century.
Dr. Martin Luther King, Jr., has written of the singular influence
Gandhi's message of nonviolent resistance had on him when he first
learned of it while studying at Crozier Theological Seminary in
Philadelphia. He would later describe that influence in his first book,
``Stride Toward Freedom'':
As I read I became deeply fascinated by [Gandhi's]
philosophy of non-violent resistance . . . as I delved deeper
into the philosophy of Gandhi, my skepticism concerning the
power of love gradually diminished, and I came to see its
potency in the area of social reform . . . prior to reading
Gandhi, I had concluded that the love ethics of Jesus were
only effective in individual relationships . . . but after
reading Gandhi, I saw how utterly mistaken I was.
. . . It was in this Gandhian emphasis on love and non-
violence that I discovered the method for social reform that
I had been seeking for so many months . . . I came to feel
that this was the only morally and practically sound method
open to oppressed people in their struggle for freedom . . .
this principle became the guiding light of our movement.
Christ furnished the spirit and motivation and Gandhi
furnished the method.
Martin Luther King, Jr., believed that Gandhi's philosophy of
nonviolent resistance was the guiding light of the American civil
rights movement. As Dr. King wrote, ``Gandhi furnished the message.'' A
statue of Gandhi, given as a gift from the Government of India, on a
small plot of Federal land along Massachusetts Avenue, in front of the
Indian Embassy, will stand not only as a tribute to the shared values
of the two largest democracies in the world but will also pay tribute
to the lasting influence of Gandhian thought on the United States. An
influence that is so pervasive that when the President and the Prime
Minister of India meet at the White House for lunch, a half-century
after Gandhi's death, it is no surprise that he should be a topic of
conversation.
______
By Mr. CHAFEE (for himself, Mr. Breaux, Mr. Kerrey, and Mr.
Conrad):
S. 864. A bill to amend title XIX of the Social Security Act to
improve the provision of managed care under the Medicaid Program; to
the Committee on Finance.
The Medicaid Managed Care Act of 1997
Mr. CHAFEE. Mr. President, I am pleased today to introduce The
Medicaid Managed Care Act of 1997. This legislation meets two very
important objectives in the Medicaid Program. First, it gives States
the additional flexibility they need to administer the Medicaid Program
by allowing them to enroll Medicaid beneficiaries into managed care
Programs. Second, the bill sets Federal standards for managed care to
ensure that Medicaid patients receive the same quality of care as those
patients who are enrolled in private managed care plans.
Under our legislation, States could require Medicaid patients to
enroll in managed care plans without going through the lengthy and
cumbersome process of applying to the Secretary of Health and Human
Services for a waiver of current Medicaid regulations. In exchange for
this important flexibility, States will have to meet a set of minimum
Federal standards to ensure that Medicaid patients continue to receive
quality care.
For example, States would be required to offer patients a choice of
at least two health plans. Plans would be required to meet certain
standards of access to care, quality, and solvency. These standards are
especially important given recent problems in States that have set up
Medicaid managed care programs under the waiver process. In some
instances, plans have failed to contract with enough providers to serve
the Medicaid population. Some have been permitted to operate under
standards that are lower than commercial insurers are required to meet,
and others have used fraudulent marketing practices to entice Medicaid
patients to sign up with their plans. These actions have resulted in
patients being denied medically necessary services, and have resulted
in States and the Federal Government paying for care that was never
given.
Considering these abuses, why should we allow Medicaid managed care
at all? Because managed care, if implemented correctly, can vastly
improve the quality of health care provided to low-income families. In
today's fee-for-service program, patients face myriad problems. Some
are forced to get care in hospital emergency rooms because they cannot
find a private physician willing or able to accept Medicaid's low
payment rates. Those who do have access to providers often must wait
for hours in clinics which are overcrowded and understaffed. And,
sadly, they often do not have access to primary and preventive care
services which would have prevented them from becoming ill to begin
with.
Medicaid managed care, if done well, provides regular prenatal care
to assure that children are born healthy. These plans provide coverage
for check-ups and immunizations to prevent serious illnesses. And they
give patients a medical home--a provider they know they can go to if
they are sick, or a number to call if they have questions.
Medicaid managed care also has the potential of benefiting our
overall health care system by providing access to primary care
providers rather than forcing patients to make costly and unnecessary
visits to hospital emergency rooms. It gives providers the opportunity
to catch and treat, or prevent, costly health problems.
Mr. President, we have worked very hard to ensure that this
legislation strikes an appropriate balance between the needs of
Medicaid beneficiaries and the managed care companies. I want to thank
Senators Breaux and Kerrey who helped craft this legislation and are
original cosponsors. I also want to thank the many advocacy
organizations for their input and support. And I also want to thank
some of the managed care organizations who worked with us. I am
especially pleased that some of these organizations, such as the HMO
Group which is an alliance of health maintenance organizations have
endorsed this legislation. Their support is critical to the success of
Medicaid managed care.
I ask unanimous consent that the text of the legislation be included
in the Record.
There being no objection, the bill was ordered to be printed in the
Record, as follows:
S. 864
Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS; AMENDMENTS TO THE
SOCIAL SECURITY ACT.
(a) Short Title.--This Act may be cited as the ``Medicaid
Managed Care Improvement Act of 1997''.
(b) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents; amendments to the Social
Security Act.
Sec. 2. Improvements in medicaid managed care program.
``Part B--Provisions Relating to Managed Care
``Sec. 1941. Beneficiary choice; enrollment.
``Sec. 1942. Beneficiary access to services generally.
``Sec. 1943. Beneficiary access to emergency care.
``Sec. 1944. Other beneficiary protections.
``Sec. 1945. Assuring quality care.
``Sec. 1946. Protections for providers.
``Sec. 1947. Assuring adequacy of payments to medicaid managed care
organizations and entities.
``Sec. 1948. Fraud and abuse.
``Sec. 1949. Sanctions for noncompliance by managed care entities.
``Sec. 1950. Definitions; miscellaneous provisions.''
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Sec. 3. Studies and reports.
Sec. 4. Conforming amendments.
Sec. 5. Effective date; status of waivers.
(c) Amendments to Social Security Act.--Except as otherwise
specifically provided, whenever in this Act an amendment is
expressed in terms of an amendment to or repeal of a section
or other provision, the reference shall be considered to be
made to that section or other provision of the Social
Security Act.
SEC. 2. IMPROVEMENTS IN MEDICAID MANAGED CARE PROGRAM.
Title XIX is amended--
(1) by inserting after the title heading the following:
``Part A--General Provisions''; and
(2) by adding at the end the following new part:
``Part B--Provisions Relating to Managed Care
``SEC. 1941. BENEFICIARY CHOICE; ENROLLMENT.
``(a) State Options for Enrollment of Beneficiaries in
Managed Care Arrangements.--
``(1) In general.--Subject to the succeeding provisions of
this part and notwithstanding paragraphs (1), (10)(B), and
(23)(A) of section 1902(a), a State may require an individual
who is eligible for medical assistance under the State plan
under this title and who is not a special needs individual
(as defined in subsection (e)) to enroll with a managed care
entity (as defined in section 1950(a)(1)) as a condition of
receiving such assistance (and, with respect to assistance
furnished by or under arrangements with such entity, to
receive such assistance through the entity), if the following
provisions are met:
``(A) Entity meets requirements.--The entity meets the
applicable requirements of this part.
``(B) Contract with state.--The entity enters into a
contract with the State to provide services for the benefit
of individuals eligible for benefits under this title under
which prepaid payments to such entity are made on an
actuarially sound basis. Such contract shall specify benefits
the provision (or arrangement) for which the entity is
responsible.
``(C) Choice of coverage.--
``(i) In general.--The State permits an individual to
choose a managed care entity from managed care organizations
and primary care case providers who meet the requirements of
this part but not less than from--
``(I) 2 medicaid managed care organizations,
``(II) a medicaid managed care organization and a primary
care case management provider, or
``(III) a primary care case management provider as long as
an individual may choose between 2 primary care case
managers.
``(ii) State option.--At the option of the State, a State
shall be considered to meet the requirements of clause (i) in
the case of an individual residing in a rural area, if the
State--
``(I) requires the individual to enroll with a medicaid
managed care organization or primary care case management
provider if such organization or entity permits the
individual to receive such assistance through not less than 2
physicians or case managers (to the extent that at least 2
physicians or case managers are available to provide such
assistance in the area), and
``(II) permits the individual to obtain such assistance
from any other provider in appropriate circumstances (as
established by the State under regulations of the Secretary).
``(D) Changes in enrollment.--The State provides the
individual with the opportunity to change enrollment among
managed care entities once annually and notifies the
individual of such opportunity not later than 60 days prior
to the first date on which the individual may change
enrollment, permits individuals to change their enrollment
for cause at any time and without cause at least every 12
months, and allows individuals to disenroll without cause
within 90 days of notification of enrollment.
``(E) Enrollment priorities.--The State establishes a
method for establishing enrollment priorities in the case of
a managed care entity that does not have sufficient capacity
to enroll all such individuals seeking enrollment under which
individuals already enrolled with the entity are given
priority in continuing enrollment with the entity.
``(F) Default enrollment process.--The State establishes a
default enrollment process which meets the requirements
described in paragraph (2) and under which any such
individual who does not enroll with a managed care entity
during the enrollment period specified by the State shall be
enrolled by the State with such an entity in accordance with
such process.
``(G) Sanctions.--The State establishes the sanctions
provided for in section 1949.
``(2) Default enrollment process requirements.--The default
enrollment process established by a State under paragraph
(1)(F)--
``(A) shall provide that the State may not enroll
individuals with a managed care entity which is not in
compliance with the applicable requirements of this part;
``(B) shall provide (consistent with subparagraph (A)) for
enrollment of such an individual with a medicaid managed care
organization--
``(i) first, that maintains existing provider-individual
relationships or that has entered into contracts with
providers (such as Federally qualified health centers, rural
health clinics, hospitals that qualify for disproportionate
share hospital payments under section 1886(d)(5)(F), and
hospitals described in section 1886(d)(1)(B)(iii)) that have
traditionally served beneficiaries under this title, and
``(ii) lastly, if there is no provider described in clause
(i), in a manner that provides for an equitable distribution
of individuals among all qualified managed care entities
available to enroll individuals through such default
enrollment process, consistent with the enrollment capacities
of such entities;
``(C) shall permit and assist an individual enrolled with
an entity under such process to change such enrollment to
another managed care entity during a period (of at least 90
days) after the effective date of the enrollment; and
``(D) may provide for consideration of factors such as
quality, geographic proximity, continuity of providers, and
capacity of the plan when conducting such process.
``(b) Reenrollment of Individuals Who Regain Eligibility.--
``(1) In general.--If an individual eligible for medical
assistance under a State plan under this title and enrolled
with a managed care entity with a contract under subsection
(a)(1)(B) ceases to be eligible for such assistance for a
period of not greater than 2 months, the State may provide
for the automatic reenrollment of the individual with the
entity as of the first day of the month in which the
individual is again eligible for such assistance, and may
consider factors such as quality, geographic proximity,
continuity of providers, and capacity of the plan when
conducting such reenrollment.
``(2) Conditions.--Paragraph (1) shall only apply if--
``(A) the month for which the individual is to be
reenrolled occurs during the enrollment period covered by the
individual's original enrollment with the managed care
entity;
``(B) the managed care entity continues to have a contract
with the State agency under subsection (a)(1)(B) as of the
first day of such month; and
``(C) the managed care entity complies with the applicable
requirements of this part.
``(3) Notice of reenrollment.--The State shall provide
timely notice to a managed care entity of any reenrollment of
an individual under this subsection.
``(c) State Option of Minimum Enrollment Period.--
``(1) In general.--In the case of an individual who is
enrolled with a managed care entity under this part and who
would (but for this subsection) lose eligibility for benefits
under this title before the end of the minimum enrollment
period (defined in paragraph (2)), the State plan under this
title may provide, notwithstanding any other provision of
this title, that the individual shall be deemed to continue
to be eligible for such benefits until the end of such
minimum period, but, except for benefits furnished under
section 1902(a)(23)(B), only with respect to such benefits
provided to the individual as an enrollee of such entity.
``(2) Minimum enrollment period defined.--For purposes of
paragraph (1), the term `minimum enrollment period' means,
with respect to an individual's enrollment with an entity
under a State plan, a period, established by the State, of
not more than 6 months beginning on the date the individual's
enrollment with the entity becomes effective, except that a
State may extend such period for up to a total of 12 months
in the case of an individual's enrollment with a managed care
entity (as defined in section 1950(a)(1)) so long as such
extension is done uniformly for all individuals enrolled with
all such entities.
``(d) Other Enrollment-Related Provisions.--
``(1) Nondiscrimination.--A managed care entity may not
discriminate on the basis of health status or anticipated
need for services in the enrollment, reenrollment, or
disenrollment of individuals eligible to receive medical
assistance under a State plan under this title or by
discouraging enrollment (except as permitted by this section)
by eligible individuals.
``(2) Termination of enrollment.--
``(A) In general.--The State, enrollment broker, and
managed care entity (if any) shall permit an individual
eligible for medical assistance under the State plan under
this title who is enrolled with the entity to terminate such
enrollment for cause at any time, and without cause during
the 90-day period beginning on the date the individual
receives notice of enrollment and at least every 12 months
thereafter, and shall notify each such individual of the
opportunity to terminate enrollment under these conditions.
``(B) Fraudulent inducement or coercion as grounds for
cause.--For purposes of subparagraph (A), an individual
terminating enrollment with a managed care entity on the
grounds that the enrollment was based on fraudulent
inducement or was obtained through coercion or pursuant to
the imposition against the managed care entity of the
sanction described in section 1949(b)(3) shall be considered
to terminate such enrollment for cause.
``(C) Notice of termination.--
``(i) Notice to state.--
``(I) By individuals.--Each individual terminating
enrollment with a managed care entity under subparagraph (A)
shall do so by
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providing notice of the termination to an office of the State
agency administering the State plan under this title, the
State or local welfare agency, or an office of a managed care
entity.
``(II) By organizations.--Any managed care entity which
receives notice of an individual's termination of enrollment
with such entity through receipt of such notice at an office
of a managed care entity shall provide timely notice of the
termination to the State agency administering the State plan
under this title.
``(ii) Notice to plan.--The State agency administering the
State plan under this title or the State or local welfare
agency which receives notice of an individual's termination
of enrollment with a managed care entity under clause (i)
shall provide timely notice of the termination to such
entity.
``(3) Provision of information.--
``(A) In general.--Each State, enrollment broker, or
managed care organization shall provide all enrollment
notices and informational and instructional materials in a
manner and form which may be easily understood by enrollees
of the entity who are eligible for medical assistance under
the State plan under this title, including enrollees and
potential enrollees who are blind, deaf, disabled, or cannot
read or understand the English language.
``(B) Information to health care providers, enrollees, and
potential enrollees.--Each medicaid managed care organization
shall--
``(i) upon request, make the information described in
section 1945(e)(1)(A)available to enrollees and potential
enrollees in the organization's service area; and
``(ii) provide to enrollees and potential enrollees
information regarding all items and services that are
available to enrollees under the contract between the State
and the organization that are covered either directly or
through a method of referral and prior authorization.
``(e) Special Needs Individuals Described.--In this part,
the term `special needs individual' means any of the
following individuals:
``(1) Special needs child.--An individual who is under 19
years of age who--
``(A) is eligible for supplemental security income under
title XVI;
``(B) is described under section 501(a)(1)(D);
``(C) is a child described in section 1902(e)(3);
``(D) is receiving services under a program under part B or
part E of title IV; or
``(E) is not described in any preceding subparagraph but is
otherwise considered a child with special health care needs
who is adopted, in foster care, or otherwise in an out-of-
home placement.
``(2) Homeless individuals.--An individual who is homeless
(without regard to whether the individual is a member of a
family), including--
``(A) an individual whose primary residence during the
night is a supervised public or private facility that
provides temporary living accommodations; or
``(B) an individual who is a resident in transitional
housing.
``(3) Migrant agricultural workers.--A migratory
agricultural worker or a seasonal agricultural worker (as
such terms are defined in section 330(g)(3) of the Public
Health Service Act), or the spouse or dependent of such a
worker.
``(4) Indians.--An Indian (as defined in section 4(c) of
the Indian Health Care Improvement Act (25 U.S.C. 1603(c))).
``(5) Medicare beneficiaries.--A qualified medicare
beneficiary (as defined in section 1905(p)(1)) or an
individual otherwise eligible for benefits under title XVIII.
``(6) Disabled individuals.--Individuals who are disabled
(as determined under section 1614(a)(3)).
``(7) Persons with aids or hiv infection.--An individual
with acquired immune deficiency syndrome (AIDS) or who has
been determined to be infected with the HIV virus.
``SEC. 1942. BENEFICIARY ACCESS TO SERVICES GENERALLY.
``(a) Access to Services.--
``(1) In general.--Each managed care entity shall provide
or arrange for the provision of all medically necessary
medical assistance under this title which is specified in the
contract entered into between such entity and the State under
section 1941(a)(1)(B) for enrollees who are eligible for
medical assistance under the State plan under this title.
``(2) Primary-care-provider-to-enrollee ratio and maximum
travel time.--Each such entity shall assure adequate access
to primary care services by meeting standards, established by
the Secretary, relating to the maximum ratio of enrollees
under this title to full-time-equivalent primary care
providers available to serve such enrollees and to maximum
travel time for such enrollees to access such providers. The
Secretary may permit such a maximum ratio to vary depending
on the area and population served. Such standards shall be
based on standards commonly applied in the commercial market,
commonly used in accreditation of managed care organizations,
and standards used in the approval of waiver applications
under section 1115, and shall be consistent with the
requirements under section 1876(c)(4)(A).
``(b) Obstetrical and Gynecological Care.--
``(1) In general.--A managed care entity may not require
prior authorization by the individual's primary care provider
or otherwise restrict the individual's access to
gynecological and obstetrical care provided by a
participating provider who specializes in obstetrics and
gynecology to the extent such care is otherwise covered, and
may treat the ordering of other obstetrical and gynecological
care by such a participating provider as the prior
authorization of the primary care provider with respect to
such care under the coverage.
``(2) Construction.--Nothing in paragraph (1)(B)(ii) shall
waive any requirements of coverage relating to medical
necessity or appropriateness with respect to coverage of
gynecological care so ordered.
``(c) Specialty Care.--
``(1) Referral to specialty care for enrollees requiring
treatment by specialists.--
``(A) In general.--In the case of an enrollee under a
managed care entity and who has a condition or disease of
sufficient seriousness and complexity to require treatment by
a specialist, the entity shall make or provide for a referral
to a specialist who is available and accessible to provide
the treatment for such condition or disease.
``(B) Specialist defined.--For purposes of this subsection,
the term `specialist' means, with respect to a condition, a
health care practitioner, facility, or center (such as a
center of excellence) that has adequate expertise through
appropriate training and experience (including, in the case
of a child, an appropriate pediatric specialist) to provide
high quality care in treating the condition.
``(C) Care under referral.--Care provided pursuant to such
referral under subparagraph (A) shall be--
``(i) pursuant to a treatment plan (if any) developed by
the specialist and approved by the entity, in consultation
with the designated primary care provider or specialist and
the enrollee (or the enrollee's designee), and
``(ii) in accordance with applicable quality assurance and
utilization review standards of the entity.
Nothing in this subsection shall be construed as preventing
such a treatment plan for an enrollee from requiring a
specialist to provide the primary care provider with regular
updates on the specialty care provided, as well as all
necessary medical information.
``(D) Referrals to participating providers.--An entity is
not required under subparagraph (A) to provide for a referral
to a specialist that is not a participating provider, unless
the entity does not have an appropriate specialist that is
available and accessible to treat the enrollee's condition
and that is a participating provider with respect to such
treatment.
``(E) Treatment of nonparticipating providers.--If an
entity refers an enrollee to a nonparticipating specialist,
services provided pursuant to the approved treatment plan
shall be provided at no additional cost to the enrollee
beyond what the enrollee would otherwise pay for services
received by such a specialist that is a participating
provider.
``(2) Specialists as primary care providers.--
``(A) In general.--A managed care entity shall have a
procedure by which a new enrollee upon enrollment, or an
enrollee upon diagnosis, with an ongoing special condition
(as defined in subparagraph (C)) may receive a referral to a
specialist for such condition who shall be responsible for
and capable of providing and coordinating the enrollee's
primary and specialty care. If such an enrollee's care would
most appropriately be coordinated by such a specialist, the
entity shall refer the enrollee to such specialist.
``(B) Treatment as primary care provider.--Such specialist
shall be permitted to treat the enrollee without a referral
from the enrollee's primary care provider and may authorize
such referrals, procedures, tests, and other medical services
as the enrollee's primary care provider would otherwise be
permitted to provide or authorize, subject to the terms of
the treatment plan (referred to in paragraph (1)(C)(i)).
``(C) Ongoing special condition defined.--In this
paragraph, the term `special condition' means a physical and
mental condition or disease that--
``(i) is life-threatening, degenerative, or disabling, and
``(ii) requires specialized medical care over a prolonged
period of time.
``(D) Terms of referral.--The provisions of subparagraphs
(C) through (E) of paragraph (1) shall apply with respect to
referrals under subparagraph (A) of this paragraph in the
same manner as they apply to referrals under paragraph
(1)(A).
``(3) Standing referrals.--
``(A) In general.--A managed care entity shall have a
procedure by which an enrollee who has a condition that
requires ongoing care from a specialist may receive a
standing referral to such specialist for treatment of such
condition. If the issuer, or the primary care provider in
consultation with the medical director of the entity and the
specialist (if any), determines that such a standing referral
is appropriate, the entity shall make such a referral to such
a specialist.
``(B) Terms of referral.--The provisions of subparagraphs
(C) through (E) of paragraph (1) shall apply with respect to
referrals under subparagraph (A) of this paragraph in the
same manner as they apply to referrals under paragraph
(1)(A).
``(d) Timely Delivery of Services.--Each managed care
entity shall respond to requests from enrollees for the
delivery of medical assistance in a manner which--
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``(1) makes such assistance--
``(A) available and accessible to each such individual,
within the area served by the entity, with reasonable
promptness and in a manner which assures continuity; and
``(B) when medically necessary, available and accessible 24
hours a day and 7 days a week; and
``(2) with respect to assistance provided to such an
individual other than through the entity, or without prior
authorization, in the case of a primary care case management
provider, provides for reimbursement to the individual (if
applicable under the contract between the State and the
entity) if--
``(A) the services were medically necessary and immediately
required because of an unforeseen illness, injury, or
condition and meet the requirements of section 1943; and
``(B) it was not reasonable given the circumstances to
obtain the services through the entity, or, in the case of a
primary care case management provider, with prior
authorization.
``(e) Internal Grievance Procedure.--Each medicaid managed
care organization shall establish an internal grievance
procedure under which an enrollee who is eligible for medical
assistance under the State plan under this title, or a
provider on behalf of such an enrollee, may challenge the
denial of coverage of or payment for such assistance.
``(f) Information on Benefit Carve Outs.--Each managed care
entity shall inform each enrollee, in a written and prominent
manner, of any benefits to which the enrollee may be entitled
to medical assistance under this title but which are not made
available to the enrollee through the entity. Such
information shall include information on where and how such
enrollees may access benefits not made available to the
enrollee through the entity.
``(g) Due Process Requirements for Managed Care Entities.--
``(1) Denial of or unreasonable delay in determining
coverage as grounds for hearing.--If a managed care entity
(or entity acting an agreement with a managed care entity)--
``(A) denies coverage of or payment for medical assistance
with respect to an enrollee who is eligible for such
assistance under the State plan under this title; or
``(B) fails to make any eligibility or coverage
determination sought by an enrollee or, in the case of a
medicaid managed care organization, by a participating health
care provider or enrollee, in a timely manner, depending upon
the urgency of the situation,
the enrollee or the health care provider furnishing such
assistance to the enrollee (as applicable) may obtain a fair
hearing before, and shall be provided a timely decision by,
the State agency administering the State plan under this
title in accordance with section 1902(a)(3). Such decisions
shall be rendered as soon as possible in accordance with the
medical exigencies of the cases, and in no event later than
72 hours in the case of hearings on decisions regarding
urgent care and 5 days in the case of all other hearings.
``(2) Completion of internal grievance procedure.--Nothing
in this subsection shall require completion of an internal
grievance procedure if the procedure does not provide for
timely review of health needs considered by the enrollee's
health care provider to be of an urgent nature or is not
otherwise consistent with the requirements for such
procedures under section 1876(c).
``(h) Demonstration of Adequate Capacity and Services.--
``(1) In general.--Subject to paragraph (3), each medicaid
managed care organization shall provide the State and the
Secretary with adequate assurances (as determined by the
Secretary) that the organization, with respect to a service
area--
``(A) has the capacity to serve the expected enrollment in
such service area;
``(B) offers an appropriate range of services for the
population expected to be enrolled in such service area,
including transportation services and translation services
consisting of the principal languages spoken in the service
area;
``(C) maintains a sufficient number, mix, and geographic
distribution of providers of services included in the
contract with the State to ensure that services are available
to individuals receiving medical assistance and enrolled in
the organization to the same extent that such services are
available to individuals enrolled in the organization who are
not recipients of medical assistance under the State plan
under this title;
``(D) maintains extended hours of operation with respect to
primary care services that are beyond those maintained during
a normal business day;
``(E) provides preventive and primary care services in
locations that are readily accessible to members of the
community;
``(F) provides information concerning educational, social,
health, and nutritional services offered by other programs
for which enrollees may be eligible; and
``(G) complies with such other requirements relating to
access to care as the Secretary or the State may impose.
``(2) Proof of adequate primary care capacity and
services.--Subject to paragraph (3), a medicaid managed care
organization that contracts with a reasonable number of
primary care providers (as determined by the Secretary) and
whose primary care membership includes a reasonable number
(as so determined) of the following providers will be deemed
to have satisfied the requirements of paragraph (1):
``(A) Rural health clinics, as defined in section
1905(l)(1).
``(B) Federally-qualified health centers, as defined in
section 1905(l)(2)(B).
``(C) Clinics which are eligible to receive payment for
services provided under title X of the Public Health Service
Act.
``(3) Sufficient providers of specialized services.--
Notwithstanding paragraphs (1) and (2), a medicaid managed
care organization may not be considered to have satisfied the
requirements of paragraph (1) if the organization does not
have a sufficient number (as determined by the Secretary) of
providers of specialized services, including perinatal and
pediatric specialty care, to ensure that such services are
available and accessible.
``(i) Compliance With Certain Maternity and Mental Health
Requirements.--Each medicaid managed care organization shall
comply with the requirements of subpart 2 of part A of title
XXVII of the Public Health Service Act insofar as such
requirements apply with respect to a health insurance issuer
that offers group health insurance coverage.
``(j) Treatment of Children With Special Health Care
Needs.--
``(1) In general.--In the case of an enrollee of a managed
care entity who is a child described in section 1941(e)(1) or
who has special health care needs (as defined in paragraph
(3))--
``(A) if any medical assistance specified in the contract
with the State is identified in a treatment plan prepared for
the enrollee by a program described in subsection (c)(1) or
paragraph (3), the managed care entity shall provide (or
arrange to be provided) such assistance in accordance with
the treatment plan either--
``(i) by referring the enrollee to a pediatric health care
provider who is trained and experienced in the provision of
such assistance and who has a contract with the managed care
entity to provide such assistance; or
``(ii) if appropriate services are not available through
the managed care entity, permitting such enrollee to seek
appropriate specialty services from pediatric health care
providers outside of or apart from the managed care entity;
and
``(B) the managed care entity shall require each health
care provider with whom the managed care entity has entered
into an agreement to provide medical assistance to enrollees
to furnish the medical assistance specified in such
enrollee's treatment plan to the extent the health care
provider is able to carry out such treatment plan.
``(2) Prior authorization.--An enrollee referred for
treatment under paragraph (1)(A)(i), or permitted to seek
treatment outside of or apart from the managed care entity
under paragraph (1)(A)(ii) shall be deemed to have obtained
any prior authorization required by the entity.
``(3) Child with special health care needs.--For purposes
of paragraph (1), a child has special health care needs if
the child is receiving services under--
``(A) a program administered under part B or part H of the
Individuals with Disabilities Education Act; or
``(B) any other program for children with special health
care needs identified by the Secretary.
``SEC. 1943. BENEFICIARY ACCESS TO EMERGENCY CARE.
``(a) Prohibition of Certain Restrictions on Coverage of
Emergency Services.--
``(1) In general.--If a managed care entity provides any
benefits under a State plan with respect to emergency
services (as defined in paragraph (2)(B)), the entity shall
cover emergency services furnished to an enrollee--
``(A) without the need for any prior authorization
determination,
``(B) subject to paragraph (3), whether or not the
physician or provider furnishing such services is a
participating physician or provider with respect to such
services, and
``(C) subject to paragraph (3), without regard to any other
term or condition of such coverage (other than an exclusion
of benefits).
``(2) Emergency services; emergency medical condition.--For
purposes of this section--
``(A) Emergency medical condition based on prudent
layperson.--The term `emergency medical condition' means a
medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a
prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of
immediate medical attention to result in--
``(i) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy,
``(ii) serious impairment to bodily functions, or
``(iii) serious dysfunction of any bodily organ or part.
``(B) Emergency services.--The term `emergency services'
means--
``(i) a medical screening examination (as required under
section 1867) that is within the capability of the emergency
department of a hospital, including ancillary services
routinely available to the emergency department, to evaluate
an emergency medical condition (as defined in subparagraph
(A)), and
``(ii) within the capabilities of the staff and facilities
available at the hospital, such further medical examination
and treatment as
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are required under section 1867 to stabilize the patient.
``(C) Trauma and burn centers.--The provisions of clause
(ii) of subparagraph (B) apply to a trauma or burn center, in
a hospital, that--
``(i) is designated by the State, a regional authority of
the State, or by the designee of the State, or
``(ii) is in a State that has not made such designations
and meets medically recognized national standards.
``(3) Application of network restriction permitted in
certain cases.--
``(A) In general.--Except as provided in subparagraph (B),
if a managed care entity in relation to benefits provided
under this title denies, limits, or otherwise differentiates
in benefits or payment for benefits other than emergency
services on the basis that the physician or provider of such
services is a nonparticipating physician or provider, the
entity may deny, limit, or differentiate in coverage or
payment for emergency services on such basis.
``(B) Network restrictions not permitted in certain
exceptional cases.--The denial or limitation of, or
differentiation in, coverage or payment of benefits for
emergency services under subparagraph (A) shall not apply in
the following cases:
``(i) Circumstances beyond control of enrollee.--The
enrollee is unable to go to a participating hospital for such
services due to circumstances beyond the control of the
enrollee (as determined consistent with guidelines and
subparagraph (C)).
``(ii) Likelihood of an adverse health consequence based on
layperson's judgment.--A prudent layperson possessing an
average knowledge of health and medicine could reasonably
believe that, under the circumstances and consistent with
guidelines, the time required to go to a participating
hospital for such services could result in any of the adverse
health consequences described in a clause of subsection
(a)(2)(A).
``(iii) Physician referral.--A participating physician or
other person authorized by the plan refers the enrollee to an
emergency department of a hospital and does not specify an
emergency department of a hospital that is a participating
hospital with respect to such services.
``(C) Application of `beyond control' standards.--For
purposes of applying subparagraph (B)(i), receipt of
emergency services from a nonparticipating hospital shall be
treated under the guidelines as being `due to circumstances
beyond the control of the enrollee' if any of the following
conditions are met:
``(i) Unconscious.--The enrollee was unconscious or in an
otherwise altered mental state at the time of initiation of
the services.
``(ii) Ambulance delivery.--The enrollee was transported by
an ambulance or other emergency vehicle directed by a person
other than the enrollee to the nonparticipating hospital in
which the services were provided.
``(iii) Natural disaster.--A natural disaster or civil
disturbance prevented the enrollee from presenting to a
participating hospital for the provision of such services.
``(iv) No good faith effort to inform of change in
participation during a contract year.--The status of the
hospital changed from a participating hospital to a
nonparticipating hospital with respect to emergency services
during a contract year and the entity failed to make a good
faith effort to notify the enrollee involved of such change.
``(v) Other conditions.--There were other factors (such as
those identified in guidelines) that prevented the enrollee
from controlling selection of the hospital in which the
services were provided.
``(b) Assuring Coordinated Coverage of Maintenance Care and
Post-Stabilization Care.--
``(1) In general.--In the case of an individual who is
enrolled with a managed care entity and who has received
emergency services pursuant to a screening evaluation
conducted (or supervised) by a treating physician at a
hospital that is a nonparticipating provider with respect to
emergency services, if--
``(A) pursuant to such evaluation, the physician identifies
post-stabilization care (as defined in paragraph (3)(B)) that
is required by the enrollee,
``(B) the coverage through the entity under this title
provides benefits with respect to the care so identified and
the coverage requires (but for this subsection) an
affirmative prior authorization determination as a condition
of coverage of such care, and
``(C) the treating physician (or another individual acting
on behalf of such physician) initiates, not later than 30
minutes after the time the treating physician determines that
the condition of the enrollee is stabilized, a good faith
effort to contact a physician or other person authorized by
the entity (by telephone or other means) to obtain an
affirmative prior authorization determination with respect to
the care,
then, without regard to terms and conditions specified in
paragraph (2) the entity shall cover maintenance care (as
defined in paragraph (3)(A)) furnished to the enrollee during
the period specified in paragraph (4) and shall cover post-
stabilization care furnished to the enrollee during the
period beginning under paragraph (5) and ending under
paragraph (6).
``(2) Terms and conditions waived.--The terms and
conditions (of coverage) described in this paragraph that are
waived under paragraph (1) are as follows:
``(A) The need for any prior authorization determination.
``(B) Any limitation on coverage based on whether or not
the physician or provider furnishing the care is a
participating physician or provider with respect to such
care.
``(C) Any other term or condition of the coverage (other
than an exclusion of benefits and other than a requirement
relating to medical necessity for coverage of benefits).
``(3) Maintenance care and post-stabilization care
defined.--In this subsection:
``(A) Maintenance care.--The term `maintenance care' means,
with respect to an individual who is stabilized after
provision of emergency services, medically necessary items
and services (other than emergency services) that are
required by the individual to ensure that the individual
remains stabilized during the period described in paragraph
(4).
``(B) Post-stabilization care.--The term `post-
stabilization care' means, with respect to an individual who
is determined to be stable pursuant to a medical screening
examination or who is stabilized after provision of emergency
services, medically necessary items and services (other than
emergency services and other than maintenance care) that are
required by the individual.
``(4) Period of required coverage of maintenance care.--The
period of required coverage of maintenance care of an
individual under this subsection begins at the time of the
request (or the initiation of the good faith effort to make
the request) under paragraph (1)(C) and ends when--
``(A) the individual is discharged from the hospital;
``(B) a physician (designated by the managed care entity
involved) and with privileges at the hospital involved
arrives at the emergency department of the hospital and
assumes responsibility with respect to the treatment of the
individual; or
``(C) the treating physician and the entity agree to
another arrangement with respect to the care of the
individual.
``(5) When post-stabilization care required to be
covered.--
``(A) When treating physician unable to communicate
request.--If the treating physician or other individual makes
the good faith effort to request authorization under
paragraph (1)(C) but is unable to communicate the request
directly with an authorized person referred to in such
paragraph within 30 minutes after the time of initiating such
effort, then post-stabilization care is required to be
covered under this subsection beginning at the end of such
30-minute period.
``(B) When able to communicate request, and no timely
response.--
``(i) In general.--If the treating physician or other
individual under paragraph (1)(C) is able to communicate the
request within the 30-minute period described in subparagraph
(A), the post-stabilization care requested is required to be
covered under this subsection beginning 30 minutes after the
time when the entity receives the request unless a person
authorized by the entity involved communicates (or makes a
good faith effort to communicate) a denial of the request for
the prior authorization determination within 30 minutes of
the time when the entity receives the request and the
treating physician does not request under clause (ii) to
communicate directly with an authorized physician concerning
the denial.
``(ii) Request for direct physician-to-physician
communication concerning denial.--If a denial of a request is
communicated under clause (i), the treating physician may
request to communicate respecting the denial directly with a
physician who is authorized by the entity to deny or affirm
such a denial.
``(C) When no timely response to request for physician-to-
physician communication.--If a request for physician-to-
physician communication is made under subparagraph (B)(ii),
the post-stabilization care requested is required to be
covered under this subsection beginning 30 minutes after the
time when the entity receives the request from a treating
physician unless a physician, who is authorized by the entity
to reverse or affirm the initial denial of the care,
communicates (or makes a good faith effort to communicate)
directly with the treating physician within such 30-minute
period.
``(D) Disagreements over post-stabilization care.--If,
after a direct physician-to-physician communication under
subparagraph (C), the denial of the request for the post-
stabilization care is not reversed and the treating physician
communicates to the entity involved a disagreement with such
decision, the post-stabilization care requested is required
to be covered under this subsection beginning as follows:
``(i) Delay to allow for prompt arrival of physician
assuming responsibility.--If the issuer communicates that a
physician (designated by the entity) with privileges at the
hospital involved will arrive promptly (as determined under
guidelines) at the emergency department of the hospital in
order to assume responsibility with respect to the treatment
of the enrollee involved, the required coverage of the post-
stabilization care begins after the passage of such time
period as would allow the prompt arrival of such a physician.
``(ii) Other cases.--If the entity does not so communicate,
the required coverage of
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the post-stabilization care begins immediately.
``(6) No requirement of coverage of post-stabilization care
if alternate plan of treatment.--
``(A) In general.--Coverage of post-stabilization care is
not required under this subsection with respect to an
individual when--
``(i) subject to subparagraph (B), a physician (designated
by the entity involved) and with privileges at the hospital
involved arrives at the emergency department of the hospital
and assumes responsibility with respect to the treatment of
the individual; or
``(ii) the treating physician and the entity agree to
another arrangement with respect to the post-stabilization
care (such as an appropriate transfer of the individual
involved to another facility or an appointment for timely
followup treatment for the individual).
``(B) Special rule where once care initiated.--Required
coverage of requested post-stabilization care shall not end
by reason of subparagraph (A)(i) during an episode of care
(as determined by guidelines) if the treating physician
initiated such care (consistent with a previous paragraph)
before the arrival of a physician described in such
subparagraph.
``(7) Construction.--Nothing in this subsection shall be
construed as--
``(A) preventing a managed care entity from authorizing
coverage of maintenance care or post-stabilization care in
advance or at any time; or
``(B) preventing a treating physician or other individual
described in paragraph (1)(C) and such an entity from
agreeing to modify any of the time periods specified in
paragraphs (5) as it relates to cases involving such persons.
``(c) Information on Access to Emergency Services.--A
managed care entity, to the extent the entity offers health
insurance coverage, shall provide education to enrollees on--
``(1) coverage of emergency services (as defined in
subsection (a)(2)(B)) by the entity in accordance with the
provisions of this section,
``(2) the appropriate use of emergency services, including
use of the 911 telephone system or its local equivalent,
``(3) any cost sharing applicable to emergency services,
``(4) the process and procedures of the plan for obtaining
emergency services, and
``(5) the locations of--
``(A) emergency departments, and
``(B) other settings,
in which participating physicians and hospitals provide
emergency services and post-stabilization care.
``(d) General Definitions.--For purposes of this section:
``(1) Cost sharing.--The term `cost sharing' means any
deductible, coinsurance amount, copayment or other out-of-
pocket payment (other than premiums or enrollment fees) that
a managed care entity issuer imposes on enrollees with
respect to the coverage of benefits.
``(2) Good faith effort.--The term `good faith effort' has
the meaning given such term in guidelines and requires such
appropriate documentation as is specified under such
guidelines.
``(3) Guidelines.--The term `guidelines' means guidelines
established by the Secretary after consultation with an
advisory panel that includes individuals representing
emergency physicians, managed care entities, including at
least one health maintenance organization, hospitals,
employers, the States, and consumers.
``(4) Prior authorization determination.--The term `prior
authorization determination' means, with respect to items and
services for which coverage may be provided by a managed are
entity, a determination (before the provision of the items
and services and as a condition of coverage of the items and
services under the coverage) of whether or not such items and
services will be covered under the coverage.
``(5) Stabilize.--The term `to stabilize' means, with
respect to an emergency medical condition, to provide (in
complying with section 1867 of the Social Security Act) such
medical treatment of the condition as may be necessary to
assure, within reasonable medical probability, that no
material deterioration of the condition is likely to result
from or occur during the transfer of the individual from the
facility.
``(6) Stabilized.--The term `stabilized' means, with
respect to an emergency medical condition, that no material
deterioration of the condition is likely, within reasonable
medical probability, to result from or occur before an
individual can be transferred from the facility, in
compliance with the requirements of section 1867 of the
Social Security Act.
``(7) Treating physician.--The term `treating physician'
includes a treating health care professional who is licensed
under State law to provide emergency services other than
under the supervision of a physician.
``SEC. 1944. OTHER BENEFICIARY PROTECTIONS.
``(a) Protecting Enrollees Against the Insolvency of
Managed Care Entities and Against the Failure of the State to
Pay Such Entities.--Each managed care entity shall provide
that an individual eligible for medical assistance under the
State plan under this title who is enrolled with the entity
may not be held liable--
``(1) for the debts of the managed care entity, in the
event of the medicaid managed care organization's insolvency;
``(2) for services provided to the individual--
``(A) in the event of the medicaid managed care
organization failing to receive payment from the State for
such services; or
``(B) in the event of a health care provider with a
contractual or other arrangement with the medicaid managed
care organization failing to receive payment from the State
or the managed care entity for such services; or
``(3) for the debts of any health care provider with a
contractual or other arrangement with the medicaid managed
care organization to provide services to the individual, in
the event of the insolvency of the health care provider.
``(b) Protection of Beneficiaries Against Balance Billing
Through Subcontractors.--
``(1) In general.--Any contract between a managed care
entity that has an agreement with a State under this title
and another entity under which the entity (or any other
entity pursuant to the contract) provides directly or
indirectly for the provision of services to beneficiaries
under the agreement with the State shall include such
provisions as the Secretary may require in order to assure
that the entity complies with balance billing limitations and
other requirements of this title (such as limitation on
withholding of services) as they would apply to the managed
care entity if such entity provided such services directly
and not through a contract with another entity.
``(2) Application of sanctions for violations.--The
provisions of
Amendments:
Cosponsors:
