‘‘(I) representatives of the orga-
nization, 
including 
physicians,
nonphysicians, 
administrators, 
and
enrollees;
‘‘(II) consumers who are not en-
rollees and those who have disenrolled;
and
‘‘(III) providers with expertise in
the field of medicine which neces-
sitates treatment.
‘‘(iii) DEADLINE
FOR
DECISION.—A
board of appeals shall hear and resolve
complaints within 30 days after the date
the complaint is filed with the board.
‘‘(C) APPEAL TO SECRETARY.—A member
enrolled in an eligible organization under this
section who is dissatisfied with a determination
of a board of appeals of the organization under
subparagraph (B) is entitled, if the amount in
controversy is $100 or more, to a hearing be-
fore the Secretary to the same extent as is pro-
vided in section 205(b), and in any such hear-
ing the Secretary shall make the eligible organi-
zation a party. If the amount in controversy is
$1,000 or more, the individual or eligible orga-
nization shall, upon notifying the other party,
be entitled to judicial review of the Secretary’s
final decision as provided in section 205(g), and
both the individual and the eligible organization
shall be entitled to be parties to that judicial re-
view. In applying sections 205(b) and 205(g) as
provided in this subparagraph, and in applying
section 205(l) thereto, any reference therein to
the Commissioner of Social Security or the So-
cial Security Administration shall be considered
a reference to the Secretary or the Department
of Health and Human Services, respectively.
‘‘(6) NOTICE
OF
ENROLLEE
RIGHTS
AND
CONSUMER REPORT CARD.—
‘‘(A) IN GENERAL.—Each eligible organi-
zation shall provide each enrollee, at the time of
enrollment and not less frequently than annu-
ally thereafter, an explanation of the enrollee’s
rights under this section and a copy of the most
recent consumer report card for the organiza-
tion (as described in subparagraph (C)).
‘‘(B) RIGHTS
DESCRIBED.—The expla-
nation of rights under subparagraph (A) shall
include an explanation of—
‘‘(i) the enrollee’s rights to benefits
from the organization;
‘‘(ii) the restrictions on payments
under this title for services furnished other
than by or through the organization;
‘‘(iii) out-of-area coverage provided by
the organization;
‘‘(iv) the organization’s coverage of
emergency services and urgently needed
care;
‘‘(v) the organization’s coverage of
out-of-network services, including services
that are additional to the items and serv-
ices covered under parts A and B; and
‘‘(vi) appeal rights of enrollees.
‘‘(C) CONSUMER REPORT CARD.—For pur-
poses of subparagraph (A), the term ‘consumer
report card’ means, with respect to an eligible
organization for a year, a report issued by the
organization which contains indicators of the
quality of the services under this section pro-
vided by the organization during the year. In-
formation must be provided in a manner that
permits consumers to compare organizations
with respect to the following:
‘‘(i) For each plan, on—
‘‘(I) the premium for the plan,
‘‘(II) identity, location, qualifica-
tions, and availability of providers in
any provider networks of the plan,
‘‘(III) the number of individuals
enrolling and disenrolling from the
plan,
‘‘(IV) procedures used by the
plan to control utilization of services
and expenditures,
‘‘(V) procedures used by the plan
to assure quality of care,
‘‘(VI) the plan’s loss ratio, and
‘‘(VII) rights and responsibilities
of enrollees.
‘‘(ii) In addition, for each managed
care plan, on—
‘‘(I) restrictions on payment for
services provided outside the plan’s
provider network,
‘‘(II) the process by which serv-
ices may be obtained through the
plan’s provider network,
‘‘(III) coverage for out-of-area
services, and
‘‘(IV) any exclusions in the types
of providers participating in the plan’s
provider network.
‘‘(7) RESTRICTIONS ON PROVIDER INCENTIVE
PLANS.—
‘‘(A) IN GENERAL.—Each contract with an
eligible organization under this section shall
provide that the organization may not operate
any provider incentive plan (as defined in sub-
paragraph (B)) unless the following require-
ments are met:
‘‘(i) No specific payment is made di-
rectly or indirectly under the plan to a pro-
vider or provider group as an inducement
to reduce or limit medically necessary serv-
ices provided with respect to a specific in-
dividual enrolled with the organization.
‘‘(ii) If the plan places a provider or
provider group at substantial financial risk
(as determined by the Secretary) for serv-
ices not provided by the provider or pro-
vider group, the organization—