Medicare and Medicaid Health Plan Beneficiary Orientation and Medical Profile Act of 1996

Summary: Medicare and Medicaid Health Plan Beneficiary Orientation and Medical Profile Act of 1996 - Amends title XVIII (Medicare) of the Social Security Act (SSA) to prohibit any payments except to those entities which certify to the Secretary of Health and Human Services that they provide for orientation and medical profiles for enrollees. 
Applies the same requirement to payments under SSA title XIX (Medicaid), plus a requirement for appropriate immunizations of child enrollees. 
Directs the Secretary to promulgate requirements for orientation and medical profiles.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare and Medicaid Health Plan 
Beneficiary Orientation and Medical Profile Act of 1996''.

SEC. 2. PROHIBITION ON PAYMENTS UNDER MEDICARE UNTIL COMPLETION OF 
              ORIENTATION AND MEDICAL PROFILE.

    (a) In General.--Section 1876(c)(3) of the Social Security Act (42 
U.S.C. 1395mm(c)(3)) is amended by adding at the end the following:
    ``(G)(i) The Secretary may not make a payment to an eligible 
organization under a risk-sharing contract under this section with 
respect to an enrollee until the eligible organization certifies to the 
Secretary that the organization--
            ``(I) has provided the enrollee an orientation as described 
        in clause (ii), and
            ``(II) has a medical profile described in clause (iii) with 
        respect to the enrollee.
    ``(ii) The orientation required under this subparagraph includes an 
explanation of the following features of the health plan offered by 
such organization:
            ``(I) Access to care, including choice of physician, 
        physician location, and hospital coverage.
            ``(II) Utilization review procedures and referral 
        practices.
            ``(III) Payment structures (including any deductible), 
        additional health care services available with or without a fee 
        (and the amount of any such fee), applicable coverage packages, 
        and copayment rates.
            ``(IV) Any physician incentive plan that such organization 
        operates under the health plan.
            ``(V) Any other procedures required under the plan that 
        affect access to care.
    ``(iii) The medical profile described in this clause is such 
profile of the medical condition of the enrollee as the Secretary shall 
specify by regulation.''.
    (b) Promulgation of Requirements for Orientation and Medical 
Profile.--Not later that 180 days after the date of the enactment of 
this Act, the Secretary of Health and Human Services shall, by rule, 
first specify the elements of the orientation and of the medical 
profile described in clauses (ii) and (iii) of section 1876(c)(3)(G) of 
the Social Security Act (as added by subsection (a)). Chapter 8 of 
title 5, United States Code, shall not apply to such rule. Such rule 
shall apply on a final basis, pending notice and opportunity for public 
comment.
    (c) Effective Date.--The amendment made by subsection (a) applies 
with respect to enrollees as of the first day of the first month that 
begins more than 60 days after the date on which the Secretary first 
publishes the rule under subsection (b) in the Federal Register.

SEC. 3. PROHIBITION ON PAYMENTS UNDER MEDICAID UNTIL COMPLETION OF 
              ORIENTATION, MEDICAL PROFILE, AND IMMUNIZATION.

    (a) Requirement for Orientation and Medical Profile.--
            (1) In general.--Notwithstanding any other provision of 
        law, no payment shall be made to a State under title XIX of the 
        Social Security Act with respect to expenditures incurred by it 
        for payment (determined under a prepaid capitation basis or 
        under any other risk basis) for services provided by any entity 
        (including a health insuring organization) for an individual 
        enrolled with the entity until the entity certifies to the 
        Secretary of Health and Human Services that--
                    (A) the entity has provided the enrollee with such 
                orientation as the Secretary of Health and Human 
                Services specifies, which orientation shall include the 
                explanation of rights described in paragraph (2) and 
                the explanation of access to care described in 
                paragraph (3);
                    (B) the entity has a medical profile described in 
                section 1876(c)(3)(G)(iii) of the Social Security Act 
                (as added by section 2(a)) with respect to the 
                enrollee; and
                    (C) if the entity is responsible for the provision 
                (directly or through arrangements with providers of 
                services) of immunizations for an enrollee who is a 
                child--
                            (i) the entity has obtained the 
                        immunization status of such child, and
                            (ii) the entity has begun to provide (or is 
                        providing) for immunizations of such child in 
                        accordance with the standards established for 
                        early and periodic screening, diagnostic, and 
                        treatment services under such title.
            (2) Explanation of rights.--The explanation of rights 
        described in this paragraph shall include an explanation of an 
        enrollee's rights under such title in relation to enrollment 
        with the entity, including an explanation of--
            (A) the enrollee's rights to benefits from the entity,
            (B) the restrictions on payments under such title for 
        services furnished other than by or through the entity,
            (C) out-of-area coverage provided by the entity,
            (D) the entity's coverage of emergency services and 
        urgently needed care, and
            (E) appeal rights of enrollees.
            (3) Explanation of access to care.--The explanation of 
        access to care described in this paragraph includes an 
        explanation of the following features of the benefits offered 
        by the entity under such title:
                    (A) Access to care, including choice of physician, 
                physician location, and hospital coverage.
                    (B) Utilization review procedures and referral 
                practices.
                    (C) Payment structures and benefits.
                    (D) Any physician incentive plan that such entity 
                operates in relation to the enrollee.
                    (E) Any other procedures required by the entity 
                that affect access of the enrollee to care.
    (b) Promulgation of Requirements for Orientation and Medical 
Profile.--Not later that 180 days after the date of the enactment of 
this Act, the Secretary of Health and Human Services shall, by rule, 
first specify the elements of the orientation and of the medical 
profile described in paragraphs (2) and (3) of subsection (a). Chapter 
8 of title 5, United States Code, shall not apply to such rule. Such 
rule shall apply on a final basis, pending notice and opportunity for 
public comment.
    (c) Effective Dates.--
            (1) In general.--Subject to paragraph (2), subsection (a) 
        applies with respect to enrollees as of the date that is 60 
        days after the date on which the Secretary first publishes the 
        rule under subsection (b) in the Federal Register.
            (2) Immunization requirements.--Subsection (a)(1)(C) 
        applies with respect to enrollees as of the first day of the 
        first month that begins more than 60 days after the date on 
        which the Secretary first publishes the rule under subsection 
        (b) in the Federal Register.