I

104TH CONGRESS

2D SESSION H. R. 4160

To amend titles XVIII and XIX of the Social Security Act to require Medicare

and Medicaid health plans to provide for orientation and medical profiles

for enrollees and to require Medicaid health plans to assure appropriate

immunizations for children.

IN THE HOUSE OF REPRESENTATIVES

SEPTEMBER 24, 1996

Mr. STARK introduced the following bill; which was referred to the Committee

on Commerce, and in addition to the Committee on 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 amend titles XVIII and XIX of the Social Security Act

to require Medicare and Medicaid health plans to provide

for orientation and medical profiles for enrollees and

to require Medicaid health plans to assure appropriate

immunizations for children.

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 and Medicaid

5 Health Plan Beneficiary Orientation and Medical Profile

6 Act of 1996’’.
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1 SEC. 2. PROHIBITION ON PAYMENTS UNDER MEDICARE

2 UNTIL COMPLETION OF ORIENTATION AND

3 MEDICAL PROFILE.

4 (a) IN GENERAL.—Section 1876(c)(3) of the Social

5 Security Act (42 U.S.C. 1395mm(c)(3)) is amended by

6 adding at the end the following:

7 ‘‘(G)(i) The Secretary may not make a payment to

8 an eligible organization under a risk-sharing contract

9 under this section with respect to an enrollee until the eli10 gible organization certifies to the Secretary that the orga11 nization—

12 ‘‘(I) has provided the enrollee an orientation as

13 described in clause (ii), and

14 ‘‘(II) has a medical profile described in clause

15 (iii) with respect to the enrollee.

16 ‘‘(ii) The orientation required under this subpara17 graph includes an explanation of the following features of

18 the health plan offered by such organization:

19 ‘‘(I) Access to care, including choice of physi20 cian, physician location, and hospital coverage.

21 ‘‘(II) Utilization review procedures and referral

22 practices.

23 ‘‘(III) Payment structures (including any de24 ductible), additional health care services available

25 with or without a fee (and the amount of any such
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1 fee), applicable coverage packages, and copayment

2 rates.

3 ‘‘(IV) Any physician incentive plan that such

4 organization operates under the health plan.

5 ‘‘(V) Any other procedures required under the

6 plan that affect access to care.

7 ‘‘(iii) The medical profile described in this clause is

8 such profile of the medical condition of the enrollee as the

9 Secretary shall specify by regulation.’’.

10 (b) PROMULGATION OF REQUIREMENTS FOR ORI11 ENTATION AND MEDICAL PROFILE.—Not later that 180

12 days after the date of the enactment of this Act, the Sec13 retary of Health and Human Services shall, by rule, first

14 specify the elements of the orientation and of the medical

15 profile described in clauses (ii) and (iii) of section

16 1876(c)(3)(G) of the Social Security Act (as added by sub17 section (a)). Chapter 8 of title 5, United States Code, shall

18 not apply to such rule. Such rule shall apply on a final

19 basis, pending notice and opportunity for public comment.

20 (c) EFFECTIVE DATE.—The amendment made by

21 subsection (a) applies with respect to enrollees as of the

22 first day of the first month that begins more than 60 days

23 after the date on which the Secretary first publishes the

24 rule under subsection (b) in the Federal Register.
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1 SEC. 3. PROHIBITION ON PAYMENTS UNDER MEDICAID

2 UNTIL COMPLETION OF ORIENTATION, MEDI3 CAL PROFILE, AND IMMUNIZATION.

4 (a) REQUIREMENT FOR ORIENTATION AND MEDICAL

5 PROFILE.—

6 (1) IN GENERAL.—Notwithstanding any other

7 provision of law, no payment shall be made to a

8 State under title XIX of the Social Security Act with

9 respect to expenditures incurred by it for payment

10 (determined under a prepaid capitation basis or

11 under any other risk basis) for services provided by

12 any entity (including a health insuring organization)

13 for an individual enrolled with the entity until the

14 entity certifies to the Secretary of Health and

15 Human Services that—

16 (A) the entity has provided the enrollee

17 with such orientation as the Secretary of

18 Health and Human Services specifies, which

19 orientation shall include the explanation of

20 rights described in paragraph (2) and the expla21 nation of access to care described in paragraph

22 (3);

23 (B) the entity has a medical profile de24 scribed in section 1876(c)(3)(G)(iii) of the So25 cial Security Act (as added by section 2(a))

26 with respect to the enrollee; and
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1 (C) if the entity is responsible for the pro2 vision (directly or through arrangements with

3 providers of services) of immunizations for an

4 enrollee who is a child—

5 (i) the entity has obtained the immu6 nization status of such child, and

7 (ii) the entity has begun to provide

8 (or is providing) for immunizations of such

9 child in accordance with the standards es10 tablished for early and periodic screening,

11 diagnostic, and treatment services under

12 such title.

13 (2) EXPLANATION OF RIGHTS.—The expla14 nation of rights described in this paragraph shall in15 clude an explanation of an enrollee’s rights under

16 such title in relation to enrollment with the entity,

17 including an explanation of—

18 (A) the enrollee’s rights to benefits from the en19 tity,

20 (B) the restrictions on payments under such

21 title for services furnished other than by or through

22 the entity,

23 (C) out-of-area coverage provided by the entity,

24 (D) the entity’s coverage of emergency services

25 and urgently needed care, and
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1 (E) appeal rights of enrollees.

2 (3) EXPLANATION OF ACCESS TO CARE.—The

3 explanation of access to care described in this para4 graph includes an explanation of the following fea5 tures of the benefits offered by the entity under such

6 title:

7 (A) Access to care, including choice of phy8 sician, physician location, and hospital coverage.

9 (B) Utilization review procedures and re10 ferral practices.

11 (C) Payment structures and benefits.

12 (D) Any physician incentive plan that such

13 entity operates in relation to the enrollee.

14 (E) Any other procedures required by the

15 entity that affect access of the enrollee to care.

16 (b) PROMULGATION OF REQUIREMENTS FOR ORI17 ENTATION AND MEDICAL PROFILE.—Not later that 180

18 days after the date of the enactment of this Act, the Sec19 retary of Health and Human Services shall, by rule, first

20 specify the elements of the orientation and of the medical

21 profile described in paragraphs (2) and (3) of subsection

22 (a). Chapter 8 of title 5, United States Code, shall not

23 apply to such rule. Such rule shall apply on a final basis,

24 pending notice and opportunity for public comment.

25 (c) EFFECTIVE DATES.—
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1 (1) IN GENERAL.—Subject to paragraph (2),

2 subsection (a) applies with respect to enrollees as of

3 the date that is 60 days after the date on which the

4 Secretary first publishes the rule under subsection

5 (b) in the Federal Register.

6 (2) IMMUNIZATION REQUIREMENTS.—Sub7 section (a)(1)(C) applies with respect to enrollees as

8 of the first day of the first month that begins more

9 than 60 days after the date on which the Secretary

10 first publishes the rule under subsection (b) in the

11 Federal Register.

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