II 

113TH CONGRESS 

2D SESSION S. 2552 

To enhance beneficiary and provider protections and improve transparency 

in the Medicare Advantage market, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JUNE 26, 2014 

Mr. BROWN (for himself and Mr. BLUMENTHAL) introduced the following bill; 

which was read twice and referred to the Committee on Finance 

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’’. 

6 SEC. 2. LIMITATION ON REMOVAL OF MEDICARE ADVAN7 TAGE PROVIDERS BY MA ORGANIZATIONS. 

8 (a) LIMITATION.—Section 1852(d) of the Social Se9 curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 

10 at the end the following: 


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1 ‘‘(7) LIMITATION ON REMOVAL OF PROVIDERS

2 FROM MA PLANS BY MA ORGANIZATIONS.— 

3 ‘‘(A) REMOVAL OF PROVIDERS WITH

4 CAUSE.—Beginning with plan year 2015, except 

5 as provided in subparagraph (C), an MA orga6 nization offering an MA plan may only remove 

7 a provider of services or a supplier from a net8 work of such plan if the organization has cause 

9 to remove such provider or supplier. 

10 ‘‘(B) CAUSE TO REMOVE PROVIDERS.— 

11 ‘‘(i) IN GENERAL.—An MA organiza12 tion offering an MA plan has cause to re13 move a provider of services or a supplier 

14 from a network of such plan if the Sec15 retary determines that the provider or sup16 plier is— 

17 ‘‘(I) medically negligent; 

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

19 contractual requirement applicable to 

20 the provider or supplier acting within 

21 the lawful scope of practice, including 

22 any participation or other requirement 

23 applicable to such provider or supplier 

24 under this title or under any contrac25 tual term for such plan; or 


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1 ‘‘(III) otherwise unfit to furnish 

2 items and services in accordance with 

3 requirements of this title. 

4 ‘‘(ii) CONSIDERATION OF COST TO MA

5 ORGANIZATIONS.—For purposes of sub6 paragraph (A), cost to an MA organization 

7 offering an MA plan due to the participa8 tion of a provider of services or supplier in 

9 a network of such plan does not constitute 

10 cause for the MA organization to remove 

11 such provider or supplier from the net12 work, and such cost may not be considered 

13 as a factor in favor of a determination that 

14 such organization has cause to remove the 

15 provider. 

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

17 upcoming plan year, beginning with plan year 

18 2015, an MA organization offering an MA plan 

19 may only remove a provider of services or sup20 plier from a network of such plan for reasons 

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

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

23 annual coordinated election period for such plan 

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

25 ‘‘(D) NOTICE AND APPEAL PROCESS.— 


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1 ‘‘(i) IN GENERAL.—Any removal of a 

2 provider of services or supplier from a net3 work of an MA plan may occur only after 

4 the completion of a fair notice and appeal 

5 process that the Secretary shall establish 

6 by regulation. Such process shall require 

7 the MA organization to provide to such 

8 provider or supplier and to the Secretary 

9 an explanation of the reason or reasons for 

10 the removal. 

11 ‘‘(ii) APPLICATION.— 

12 ‘‘(I) APPLICATION OF NEW PROC13 ESS.—In the case of a removal of a 

14 provider of services or supplier from a 

15 network of an MA plan occurring on 

16 or after the effective date published in 

17 a final rule for such fair notice and 

18 appeal process, such process shall 

19 apply in lieu of the process for the 

20 termination or suspension of a pro21 vider contract under section 

22 422.202(a) of title 42, Code of Fed23 eral Regulations. 

24 ‘‘(II) CONTINUATION OF OLD

25 PROCESS.—In the case of a removal of 


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1 a provider of services or supplier from 

2 a network of an MA plan occurring 

3 before such effective date, the process 

4 for the termination or suspension of a 

5 provider contract under section 

6 422.202(a) of title 42, Code of Fed7 eral Regulations, shall apply. 

8 ‘‘(E) PARTICIPANT NOTICE AND PROTEC9 TION.— 

10 ‘‘(i) NOTICE TO PARTICIPANTS OF

11 PROVIDER REMOVAL.—Not less than 60 

12 days before the date on which a provider 

13 of services or supplier is removed from a 

14 network of an MA plan, the MA organiza15 tion offering such plan shall provide notifi16 cation of the removal to each individual en17 rolled in such plan receiving items or serv18 ices from the provider or supplier during 

19 the plan year in effect on the date of re20 moval or during the previous plan year. 

21 Such notification shall include— 

22 ‘‘(I) the names and telephone 

23 numbers of in-network providers of 

24 services and suppliers offering items 

25 and services that are the same or 


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1 similar to the items and services of2 fered by the removed provider or sup3 plier; 

4 ‘‘(II) information regarding the 

5 options available to an individual en6 rolled in such plan to request the con7 tinuation of medical treatment or 

8 therapy with the removed provider or 

9 supplier; and 

10 ‘‘(III) one or more customer serv11 ice telephone numbers that an indi12 vidual enrolled in such plan may ac13 cess to obtain information regarding 

14 changes to the network of the plan. 

15 ‘‘(ii) ANNUAL NOTICE OF CHANGE.— 

16 In addition to providing the notification of 

17 removal as required under clause (i), the 

18 MA organization offering such MA plan 

19 shall include such notification in the an20 nual notice of change for the MA plan for 

21 the upcoming plan year. 

22 ‘‘(iii) CONTINUITY OF CARE.—In any 

23 case in which a provider of services or sup24 plier is removed from a network of an MA 

25 plan, such plan shall ensure that the reVerDate Mar 15 2010 02:03 Jul 08, 2014 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S2552.IS S2552

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1 moval satisfies the continuity of care re2 quirements under paragraph (1)(A) with 

3 respect to each individual enrolled in such 

4 plan receiving items or services from the 

5 provider or supplier during the plan year 

6 in effect on the date of removal or during 

7 the previous plan year. 

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

9 in this paragraph shall be construed as affect10 ing the ability of a provider of services or sup11 plier to decline to participate in a network of an 

12 MA plan. 

13 ‘‘(8) TRANSPARENCY IN MEASURES USED BY

14 MA ORGANIZATIONS TO ESTABLISH OR MODIFY PRO15 VIDER NETWORKS.— 

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

17 year 2016, an MA organization offering an MA 

18 plan shall include the information described in 

19 subparagraph (B)— 

20 ‘‘(i) in the annual bid information 

21 submitted by the MA organization with re22 spect to the MA plan under section 1854; 

23 and 

24 ‘‘(ii) on the Internet Web Site for the 

25 MA plan. 


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1 ‘‘(B) INFORMATION DESCRIBED.—The in2 formation described in this subparagraph is the 

3 following: 

4 ‘‘(i) Information regarding the meas5 ures used by the MA organization to estab6 lish or modify the provider network of the 

7 MA plan, including measures of the quality 

8 and efficiency of providers. Such informa9 tion shall include the specifications, meth10 odology, and sample size of such measures. 

11 ‘‘(ii) Other information related to the 

12 establishment or modification of such pro13 vider network that the Secretary deter14 mines appropriate. 

15 ‘‘(C) LIMITATION.—The information de16 scribed in subparagraph (B) shall not include 

17 any individually identifiable information of any 

18 provider or supplier of services.’’. 

19 (b) ENFORCEMENT.— 

20 (1) SANCTIONS FOR NONCOMPLIANCE.—Section 

21 1857(g)(1) of the Social Security Act (42 U.S.C. 

22 1395w–27(g)(1)) is amended— 

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

24 (B) by redesignating subparagraph (K) as 

25 subparagraph (L); 


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1 (C) by inserting after subparagraph (J) 

2 the following new subparagraph: 

3 ‘‘(K) fails to comply with sections 

4 1852(d)(7) or 1852(d)(8); or’’; and 

5 (D) in subparagraph (L) (as so redesig6 nated), by striking ‘‘through (J)’’ and inserting 

7 ‘‘through (K)’’. 

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

9 Title XVIII of the Social Security Act is amended— 

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

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

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

13 (1)(F) and (1)(K)’’; and 

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

15 1395eee(e)(6)(B)), by inserting ‘‘(other than 

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

17 ‘‘1857(g)(1)’’. 

18 (c) NETWORK ACCESS ADEQUACY STANDARDS.—Be19 ginning with plan year 2015, in applying the network ac20 cess adequacy standards pursuant to section 1852(d)(1) 

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

22 the Secretary of Health and Human Services shall seek 

23 input from patient advocacy groups, providers of services 

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

25 of such Act. 


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1 (d) MEDICARE ADVANTAGE PLAN COMPARE TOOL.— 

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

3 Health and Human Services shall take such measures as 

4 are necessary to ensure that the Medicare Advantage 

5 Compare Tool takes into account the preferences and utili6 zation needs of such individuals. 

Æ 


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