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104TH CONGRESS

2D SESSION H. R. 3079

To amend title XVIII of the Social Security Act to assure access to services

under the Medicare Health Maintenance Organization Program.

IN THE HOUSE OF REPRESENTATIVES

MARCH 13, 1996

Mr. COBURN (for himself and Mr. BROWN of Ohio) introduced the following

bill; which was referred to the Committee on Ways and Means, and in

addition to the Committee on Commerce, for a period to be subsequently

determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To amend title XVIII of the Social Security Act to assure

access to services under the Medicare Health Maintenance Organization Program.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. ASSURING ACCESS TO SERVICES UNDER THE

4 MEDICARE HMO PROGRAM.

5 (a) ADEQUATE PROVIDER ARRANGEMENTS.—Section

6 1876(c)(4)(A) of the Social Security Act (42 U.S.C.

7 1395mm(c)(4)(A)) is amended by inserting ‘‘establish and

8 maintain adequate arrangements with a sufficient num-
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1 ber, mix, and distribution of health professionals to’’ after

2 ‘‘(A)’’.

3 (b) PHYSICIAN PARTICIPATION RULES.—Section

4 1876(c) of such Act is amended by adding at the end the

5 following new paragraph:

6 ‘‘(9) An eligible organization must—

7 ‘‘(A) provide for the full participation of all

8 eligible physicians—

9 ‘‘(i) who are graduates of either

10 allopathic or osteopathic medical schools,

11 and

12 ‘‘(ii) who have received training from

13 programs approved by either the Accredi14 tation Council for Graduate Medical Edu15 cation or the American Osteopathic Asso16 ciation; and

17 ‘‘(B) not discriminate against a health

18 physician, based solely on the physician’s cer19 tification or license (as applicable under State

20 law), in participation in providing covered

21 health services or reimbursement or indem22 nification for providing such services, if the

23 physician may legally provide such services in

24 accordance with State law.’’.
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1 (c) NONPHYSICIAN HEALTH CARE PROFESSIONAL

2 PARTICIPATION RULES.—Section 1876(c) of such Act is

3 further amended by adding at the end the following new

4 paragraph:

5 ‘‘(9) An eligible organization shall not—

6 ‘‘(A) exclude a health professional from

7 participation in its provider network based sole8 ly on—

9 ‘‘(i) the health professional’s certifi10 cation or license (as applicable under State

11 law), or

12 ‘‘(ii) the health professional’s lack of

13 affiliation with, or admitting privileges at,

14 a hospital, if such lack of affiliation is due

15 to the health professional’s type of license;

16 or

17 ‘‘(B) discriminate against a health profes18 sional, based solely on the professional’s certifi19 cation or license (as applicable under State

20 law), in participation in providing covered

21 health services or reimbursement or indem22 nification for providing such services, if the pro23 fessional may legally provide such services in

24 accordance with State law.’’.
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1 (c) EFFECTIVE DATE.—The amendments made by

2 this section shall apply to contract years beginning on or

3 after the date of enactment of this Act.

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