I

106TH CONGRESS

1ST SESSION H. R. 1860

To require managed care organizations to contract with providers in medically

underserved areas, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

MAY 19, 1999

Mrs. CHRISTENSEN (for herself, Mrs. JONES of Ohio, Mr. RUSH, Ms. EDDIE

BERNICE JOHNSON of Texas, Mr. CLYBURN, Mr. WYNN, Mr. THOMPSON

of Mississippi, Ms. KILPATRICK, Mrs. MEEK of Florida, Mr. MENENDEZ,

Mrs. CLAYTON, Ms. CARSON, Ms. MILLENDER-MCDONALD, Mr. WATT of

North Carolina, Mr. JEFFERSON, Ms. LEE, Mr. BISHOP, Mr. OWENS,

Mr. HILLIARD, Mr. PAYNE, Mr. DAVIS of Illinois, Ms. NORTON, Mr.

MEEKS of New York, Ms. BROWN of Florida, Mr. SCOTT, Mr. FATTAH,

Mr. CLAY, Mr. LEWIS of Georgia, Ms. JACKSON-LEE of Texas, Mr.

TOWNS, Mr. CUMMINGS, Ms. WATERS, Ms. MCKINNEY, Mr. DIXON, Mr.

CONYERS, Mr. HASTINGS of Florida, Mr. JACKSON of Illinois, Mr. FORD,

and Mr. RANGEL) introduced the following bill; which was referred to the

Committee on Commerce, and in addition to the Committees on Education and the Workforce, and Ways and Means, 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 require managed care organizations to contract with providers in medically underserved areas, and for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE; FINDINGS.

2 (a) SHORT TITLE.—This Act may be cited as the

3 ‘‘Medically Underserved Access to Care Act of 1999’’.

4 (b) FINDINGS.—Congress finds the following:

5 (1) Minority individuals living in medically un6 derserved areas are generally less well-off

7 socioeconomically, and are often sicker than the pop8 ulation that managed care organizations tradition9 ally serve.

10 (2) Many managed care organizations are not

11 equipped to deal effectively with minorities in under12 served areas and consequently may offer lower qual13 ity health care in such areas.

14 (3) Often managed care organizations do not

15 contract with physicians and other community-based

16 service providers who traditionally serve medically

17 underserved areas.

18 (4) There is a concern among minority physi19 cians that selective marketing practices and referral

20 processes may keep minority and community-based

21 physicians out of some managed care organizations.

22 (5) Managed care organizations sometimes ex23 clude physicians and other community-based health

24 care providers who traditionally provide service to

25 underserved areas; this is particularly the case

26 among minority physicians who may be well estab-
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1 lished in their community based practices but are

2 not board certified.

3 SEC. 2. REQUIREMENT FOR SERVICE TO AREAS THAT IN4 CLUDE A MEDICALLY UNDERSERVED POPU5 LATION.

6 (a) REQUIREMENT.—

7 (1) IN GENERAL.—A managed care organiza8 tion offering a managed care plan shall establish and

9 maintain adequate arrangements, as defined under

10 regulations of the Secretary, with a sufficient num11 ber, mix, and distribution of health care profes12 sionals and providers to assure that covered items

13 and services are available and accessible to each en14 rollee under the plan—

15 (A) in the service area of the organization;

16 (B) in a variety of sites of service;

17 (C) with reasonable promptness (including

18 reasonable hours of operation and after-hours

19 services);

20 (D) with reasonable proximity to the resi21 dences and workplaces of enrollees; and

22 (E) in a manner that—

23 (i) takes into account the diverse

24 needs of enrollees; and
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1 (ii) reasonably assures continuity of

2 care.

3 (2) TREATMENT OF ORGANIZATIONS SERVING

4 CERTAIN AREAS.—For a managed care organization

5 that serves a medically underserved area, the organi6 zation shall be treated as meeting the requirement

7 of paragraph (1) if the organization has arrange8 ments with a sufficient number, mix, and distribu9 tion of health care professionals and providers hav10 ing a history of serving such areas.

11 (b) ENFORCEMENT OF REQUIREMENTS.—

12 (1) APPLICATION TO GROUP HEALTH PLANS.—

13 (A) PUBLIC HEALTH SERVICE ACT.—For

14 purposes of applying title XXVII of the Public

15 Health Service Act, the requirements of sub16 section (a) shall be treated as though they were

17 included in subpart 2 of part A of such title (42

18 U.S.C. 300gg–4 et seq.).

19 (B) EMPLOYEE RETIREMENT INCOME SE20 CURITY ACT OF 1974.—For purposes of applying

21 part 7 of subtitle B of title I of the Employee

22 Retirement Income Security Act of 1974, the

23 requirements of subsection (a) shall be treated

24 as though they were included in subpart B of

25 such part (29 U.S.C. 1185 et seq.).
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1 (C) INTERNAL REVENUE CODE OF 1986.—

2 For purposes of applying chapter 100 of the In3 ternal Revenue Code of 1986, the requirements

4 of subsection (a) shall be treated as though

5 they were included in subchapter B of such

6 chapter.

7 (2) APPLICATION TO INDIVIDUAL HEALTH IN8 SURANCE COVERAGE.—For purposes of applying

9 title XXVII of the Public Health Service Act, the re10 quirements of subsection (a) also shall be treated as

11 though they were part of subpart 2 of part B of

12 such title (42 U.S.C. 300gg–51 et seq.).

13 (3) MEDICARE.—The Secretary may not enter

14 into a contract under section 1857 of the Social Se15 curity Act (42 U.S.C. 1395w–27) with a

16 Medicare+Choice organization that is a managed

17 care organization unless the contract contains assur18 ances satisfactory to the Secretary that the organi19 zation will comply with the applicable requirements

20 of subsection (a) of this Act.

21 (4) MEDICAID.—Notwithstanding any other

22 provision of law, no funds shall be paid to a State

23 under section 1903(a)(1) of the Social Security Act

24 (42 U.S.C. 1396b(a)(1)) with respect to medical as25 sistance provided through payment to a medicaid
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1 managed care organization (as defined in section

2 1903(m)(1)(A) of such Act, 42 U.S.C.

3 1396b(m)(1)(A)) unless the contract with such orga4 nization contains assurances satisfactory to the Sec5 retary that the organization will comply with the ap6 plicable requirements of subsection (a) of this Act.

7 SEC. 3. ESTABLISHMENT OF GRANT PROGRAM.

8 (a) IN GENERAL.—The Secretary shall establish a

9 program in the Office of Minority Health of the Depart10 ment of Health and Human Services to award competitive

11 grants to eligible nongovernmental agencies to enable such

12 agencies to develop outreach programs to—

13 (1) inform individuals in medically underserved

14 areas how to access managed care organizations in

15 their communities; and

16 (2) assist physicians and other health care pro17 fessionals who serve in medically underserved areas

18 to enroll as providers in managed care organizations

19 in their communities.

20 (b) ELIGIBILITY AND AMOUNT.—

21 (1) ELIGIBILITY.—The criteria necessary to re22 ceive a grant under this section shall be determined

23 by the Secretary.
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1 (2) AMOUNT.—The amount of a grant awarded

2 to an agency under this section shall be determined

3 by the Secretary.

4 SEC. 4. DEFINITIONS.

5 For purposes of this Act:

6 (1) ENROLLEE.—The term ‘‘enrollee’’ means,

7 with respect to a managed care plan offered by a

8 managed care organization, an individual enrolled

9 with the organization for coverage under such a

10 plan.

11 (2) HEALTH CARE PROFESSIONAL.—The term

12 ‘‘health care professional’’ means a physician or

13 other health care practitioner who is licensed under

14 State law with respect to the health care services the

15 practitioner furnishes.

16 (3) HEALTH PLAN.—The term ‘‘health plan’’

17 means a group health plan or health insurance cov18 erage offered by a health insurance issuer.

19 (4) MANAGED CARE ORGANIZATION.—The term

20 ‘‘managed care organization’’ means any entity, in21 cluding a group health plan, health maintenance or22 ganization, or provider-sponsored organization, in re23 lation to its offering of a managed care plan, and in24 cludes any other entity that provides or manages the
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1 coverage under such a plan under a contract or ar2 rangement with the entity.

3 (5) MANAGED CARE PLAN.—The term ‘‘man4 aged care plan’’ means a health plan offered by an

5 entity if the entity—

6 (A) provides or arranges for the provision

7 of health care items and services to enrollees in

8 the plan through participating health care pro9 fessionals and providers; or

10 (B) provides financial incentives (such as

11 variable copayments and deductibles) to induce

12 enrollees to obtain benefits through partici13 pating health care professionals and providers,

14 or both.

15 (6) MEDICALLY UNDERSERVED AREA.—The

16 term ‘‘medically underserved area’’ means an area

17 that is designated as a health professional shortage

18 area under section 332 of the Public Health Service

19 Act (42 U.S.C. 254e) or as a medically underserved

20 area for purposes of section 330 or 1302(7) of such

21 Act (42 U.S.C. 254c, 300e–1(7)).

22 (7) PARTICIPATING.—The term ‘‘participating’’

23 means, with respect to a health care professional or

24 provider in relation to a health plan offered by an

25 entity, a physician or provider that furnishes health
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1 care items and services to enrollees of the entity

2 under an agreement with the entity.

3 (8) PRIMARY CARE PROVIDER.—The term ‘‘pri4 mary care provider’’ means a health care profes5 sional who acts as a gatekeeper for the overall care

6 of an enrollee.

7 (9) SECRETARY.—The term ‘‘Secretary’’ means

8 the Secretary of Health and Human Services .

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