I 

113TH CONGRESS 

2D SESSION H. R. 4998 

To enhance beneficiary and provider protections and improve transparency 

in the Medicare Advantage market, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 26, 2014 

Ms. DELAURO introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and 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 enhance beneficiary and provider protections and improve 

transparency in the Medicare Advantage market, 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, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medicare Advantage 

5 Participant Bill of Rights Act of 2014’’. 


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1 SEC. 2. LIMITATION ON REMOVAL OF MEDICARE ADVAN2 TAGE PROVIDERS BY MA ORGANIZATIONS. 

3 (a) LIMITATION.—Section 1852(d) of the Social Se4 curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 

5 at the end the following: 

6 ‘‘(7) LIMITATION ON REMOVAL OF PROVIDERS

7 FROM MA PLANS BY MA ORGANIZATIONS.— 

8 ‘‘(A) REMOVAL OF PROVIDERS WITH

9 CAUSE.—Beginning with plan year 2015, except 

10 as provided in subparagraph (C), an MA orga11 nization offering an MA plan may only remove 

12 a provider of services or a supplier from a net13 work of such plan if the organization has cause 

14 to remove such provider or supplier. 

15 ‘‘(B) CAUSE TO REMOVE PROVIDERS.— 

16 ‘‘(i) IN GENERAL.—An MA organiza17 tion offering an MA plan has cause to re18 move a provider of services or a supplier 

19 from a network of such plan if the Sec20 retary determines that the provider or sup21 plier is— 

22 ‘‘(I) medically negligent; 

23 ‘‘(II) in violation of any legal or 

24 contractual requirement applicable to 

25 the provider or supplier acting within 

26 the lawful scope of practice, including 


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1 any participation or other requirement 

2 applicable to such provider or supplier 

3 under this title or under any contrac4 tual term for such plan; or 

5 ‘‘(III) otherwise unfit to furnish 

6 items and services in accordance with 

7 requirements of this title. 

8 ‘‘(ii) CONSIDERATION OF COST TO MA

9 ORGANIZATIONS.—For purposes of sub10 paragraph (A), cost to an MA organization 

11 offering an MA plan due to the participa12 tion of a provider of services or supplier in 

13 a network of such plan does not constitute 

14 cause for the MA organization to remove 

15 such provider or supplier from the net16 work, and such cost may not be considered 

17 as a factor in favor of a determination that 

18 such organization has cause to remove the 

19 provider. 

20 ‘‘(C) EXCEPTION.—With respect to each 

21 upcoming plan year, beginning with plan year 

22 2015, an MA organization offering an MA plan 

23 may only remove a provider of services or sup24 plier from a network of such plan for reasons 

25 not specified in subparagraph (B)(i) before the 


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1 date that is 60 days before the first day of the 

2 annual coordinated election period for such plan 

3 year under section 1851(e)(3). 

4 ‘‘(D) NOTICE AND APPEAL PROCESS.— 

5 ‘‘(i) IN GENERAL.—Any removal of a 

6 provider of services or supplier from a net7 work of an MA plan may occur only after 

8 the completion of a fair notice and appeal 

9 process that the Secretary shall establish 

10 by regulation. Such process shall require 

11 the MA organization to provide to such 

12 provider or supplier and to the Secretary 

13 an explanation of the reason or reasons for 

14 the removal. 

15 ‘‘(ii) APPLICATION.— 

16 ‘‘(I) APPLICATION OF NEW PROC17 ESS.—In the case of a removal of a 

18 provider of services or supplier from a 

19 network of an MA plan occurring on 

20 or after the effective date published in 

21 a final rule for such fair notice and 

22 appeal process, such process shall 

23 apply in lieu of the process for the 

24 termination or suspension of a pro25 vider contract under section 


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1 422.202(a) of title 42, Code of Fed2 eral Regulations. 

3 ‘‘(II) CONTINUATION OF OLD

4 PROCESS.—In the case of a removal of 

5 a provider of services or supplier from 

6 a network of an MA plan occurring 

7 before such effective date, the process 

8 for the termination or suspension of a 

9 provider contract under section 

10 422.202(a) of title 42, Code of Fed11 eral Regulations, shall apply. 

12 ‘‘(E) PARTICIPANT NOTICE AND PROTEC13 TION.— 

14 ‘‘(i) NOTICE TO PARTICIPANTS OF

15 PROVIDER REMOVAL.—Not less than 60 

16 days before the date on which a provider 

17 of services or supplier is removed from a 

18 network of an MA plan, the MA organiza19 tion offering such plan shall provide notifi20 cation of the removal to each individual en21 rolled in such plan receiving items or serv22 ices from the provider or supplier during 

23 the plan year in effect on the date of re24 moval or during the previous plan year. 

25 Such notification shall include— 


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1 ‘‘(I) the names and telephone 

2 numbers of in-network providers of 

3 services and suppliers offering items 

4 and services that are the same or 

5 similar to the items and services of6 fered by the removed provider or sup7 plier; 

8 ‘‘(II) information regarding the 

9 options available to an individual en10 rolled in such plan to request the con11 tinuation of medical treatment or 

12 therapy with the removed provider or 

13 supplier; and 

14 ‘‘(III) one or more customer serv15 ice telephone numbers that an indi16 vidual enrolled in such plan may ac17 cess to obtain information regarding 

18 changes to the network of the plan. 

19 ‘‘(ii) ANNUAL NOTICE OF CHANGE.— 

20 In addition to providing the notification of 

21 removal as required under clause (i), the 

22 MA organization offering such MA plan 

23 shall include such notification in the an24 nual notice of change for the MA plan for 

25 the upcoming plan year. 


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1 ‘‘(iii) CONTINUITY OF CARE.—In any 

2 case in which a provider of services or sup3 plier is removed from a network of an MA 

4 plan, such plan shall ensure that the re5 moval satisfies the continuity of care re6 quirements under paragraph (1)(A) with 

7 respect to each individual enrolled in such 

8 plan receiving items or services from the 

9 provider or supplier during the plan year 

10 in effect on the date of removal or during 

11 the previous plan year. 

12 ‘‘(F) RULE OF CONSTRUCTION.—Nothing 

13 in this paragraph shall be construed as affect14 ing the ability of a provider of services or sup15 plier to decline to participate in a network of an 

16 MA plan. 

17 ‘‘(8) TRANSPARENCY IN MEASURES USED BY

18 MA ORGANIZATIONS TO ESTABLISH OR MODIFY PRO19 VIDER NETWORKS.— 

20 ‘‘(A) IN GENERAL.—Beginning with plan 

21 year 2016, an MA organization offering an MA 

22 plan shall include the information described in 

23 subparagraph (B)— 

24 ‘‘(i) in the annual bid information 

25 submitted by the MA organization with reVerDate Mar 15 2010 04:04 Jul 02, 2014 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H4998.IH H4998

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1 spect to the MA plan under section 1854; 

2 and 

3 ‘‘(ii) on the Internet Web site for the 

4 MA plan. 

5 ‘‘(B) INFORMATION DESCRIBED.—The in6 formation described in this subparagraph is the 

7 following: 

8 ‘‘(i) Information regarding the meas9 ures used by the MA organization to estab10 lish or modify the provider network of the 

11 MA plan, including measures of the quality 

12 and efficiency of providers. Such informa13 tion shall include the specifications, meth14 odology, and sample size of such measures. 

15 ‘‘(ii) Other information related to the 

16 establishment or modification of such pro17 vider network that the Secretary deter18 mines appropriate. 

19 ‘‘(C) LIMITATION.—The information de20 scribed in subparagraph (B) shall not include 

21 any individually identifiable information of any 

22 provider or supplier of services.’’. 

23 (b) ENFORCEMENT.— 


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1 (1) SANCTIONS FOR NONCOMPLIANCE.—Section 

2 1857(g)(1) of the Social Security Act (42 U.S.C. 

3 1395w–27(g)(1)) is amended— 

4 (A) in subparagraph (J), by striking ‘‘or’’; 

5 (B) by redesignating subparagraph (K) as 

6 subparagraph (L); 

7 (C) by inserting after subparagraph (J) 

8 the following new subparagraph: 

9 ‘‘(K) fails to comply with sections 

10 1852(d)(7) or 1852(d)(8); or’’; and 

11 (D) in subparagraph (L) (as so redesig12 nated), by striking ‘‘through (J)’’ and inserting 

13 ‘‘through (K)’’. 

14 (2) SANCTIONS NOT APPLICABLE TO PART D.— 

15 Title XVIII of the Social Security Act is amended— 

16 (A) in section 1860D–12(b)(3)(E) (42 

17 U.S.C. 1395w–112(b)(3)(E)), by striking 

18 ‘‘paragraph (1)(F)’’ and inserting ‘‘paragraphs 

19 (1)(F) and (1)(K)’’; and 

20 (B) in section 1894(e)(6)(B) (42 U.S.C. 

21 1395eee(e)(6)(B)), by inserting ‘‘(other than 

22 paragraph (1)(K) of such section)’’ after 

23 ‘‘1857(g)(1)’’. 

24 (c) NETWORK ACCESS ADEQUACY STANDARDS.—Be25 ginning with plan year 2015, in applying the network acVerDate Mar 15 2010 04:04 Jul 02, 2014 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H4998.IH H4998

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1 cess adequacy standards pursuant to section 1852(d)(1) 

2 of the Social Security Act (42 U.S.C. 1395w–22(d)(1)), 

3 the Secretary of Health and Human Services shall seek 

4 input from patient advocacy groups, providers of services 

5 and suppliers, and MA plans under part C of title XVIII 

6 of such Act. 

7 (d) MEDICARE ADVANTAGE PLAN COMPARE TOOL.— 

8 Not later than September 30, 2015, the Secretary of 

9 Health and Human Services shall take such measures as 

10 are necessary to ensure that the Medicare Advantage 

11 Compare Tool takes into account the preferences and utili12 zation needs of such individuals. 

Æ 


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