811
‘‘(3) ACCESS.—The number, mix, and distribu-
tion of plan providers.
‘‘(4) 
OUT-OF-AREA
COVERAGE.—Out-of-area
coverage provided by the plan.
‘‘(5) EMERGENCY
COVERAGE.—Coverage of
emergency services and urgently needed care, includ-
ing—
‘‘(A) the appropriate use of emergency
services, including use of the 911 telephone sys-
tem or its local equivalent in emergency situa-
tions and an explanation of what constitutes an
emergency situation;
‘‘(B) the process and procedures of the
plan for obtaining emergency services; and
‘‘(C) the locations of (i) emergency depart-
ments, and (ii) other settings, in which plan
physicians and hospitals provide emergency
services and post-stabilization care.
‘‘(6) 
SUPPLEMENTAL
BENEFITS.—Supple-
mental benefits available from the organization of-
fering the plan, including—
‘‘(A) whether the supplemental benefits are
optional,
‘‘(B) the supplemental benefits covered,
and
812
‘‘(C) the premium price for the supple-
mental benefits.
‘‘(7) PRIOR AUTHORIZATION RULES.—Rules re-
garding prior authorization or other review require-
ments that could result in nonpayment.
‘‘(8) PLAN GRIEVANCE AND APPEALS PROCE-
DURES.—Any appeal or grievance rights and proce-
dures.
‘‘(9) QUALITY
ASSURANCE
PROGRAM.—A de-
scription of the organization’s quality assurance pro-
gram under subsection (e).
‘‘(d) ACCESS TO SERVICES.—
‘‘(1) IN GENERAL.—A MedicarePlus organiza-
tion offering a MedicarePlus plan may select the
providers from whom the benefits under the plan are
provided so long as—
‘‘(A) the organization makes such benefits
available and accessible to each individual elect-
ing the plan within the plan service area with
reasonable promptness and in a manner which
assures continuity in the provision of benefits;
‘‘(B) when medically necessary the organi-
zation makes such benefits available and acces-
sible 24 hours a day and 7 days a week;
813
‘‘(C) the plan provides for reimbursement
with respect to services which are covered under
subparagraphs (A) and (B) and which are pro-
vided to such an individual other than through
the organization, if—
‘‘(i) the services were medically nec-
essary and immediately required because of
an unforeseen illness, injury, or condition,
and it was not reasonable given the cir-
cumstances to obtain the services through
the organization,
‘‘(ii) the services were renal dialysis
services and were provided other than
through the organization because the indi-
vidual was temporarily out of the plan’s
service area, or
‘‘(iii) the services are maintenance
care or post-stabilization care covered
under the guidelines established under
paragraph (2);
‘‘(D) the organization provides access to
appropriate providers, including credentialed
specialists, for medically necessary treatment
and services; and
814
‘‘(E) coverage is provided for emergency
services (as defined in paragraph (3)) without
regard to prior authorization or the emergency
care provider’s contractual relationship with the
organization.
‘‘(2) GUIDELINES RESPECTING COORDINATION
OF
POST-STABILIZATION
CARE.—A MedicarePlus
plan shall comply with such guidelines as the Sec-
retary may prescribe relating to promoting efficient
and timely coordination of appropriate maintenance
and post-stabilization care of an enrollee after the
enrollee has been determined to be stable under sec-
tion 1867.
‘‘(3) DEFINITION OF EMERGENCY SERVICES.—
In this subsection—
‘‘(A) IN GENERAL.—The term ‘emergency
services’ means, with respect to an individual
enrolled with an organization, covered inpatient
and outpatient services that—
‘‘(i) are furnished by a provider that
is qualified to furnish such services under
this title, and
‘‘(ii) are needed to evaluate or sta-
bilize an emergency medical condition (as
defined in subparagraph (B)).
815
‘‘(B) EMERGENCY
MEDICAL
CONDITION
BASED
ON
PRUDENT
LAYPERSON.—The term
‘emergency medical condition’ means a medical
condition manifesting itself by acute symptoms
of sufficient severity such that a prudent
layperson, who possesses an average knowledge
of health and medicine, could reasonably expect
the absence of immediate medical attention to
result in—
‘‘(i) placing the health of the individ-
ual (or, with respect to a pregnant woman,
the health of the woman or her unborn
child) in serious jeopardy,
‘‘(ii) serious impairment to bodily
functions, or
‘‘(iii) serious dysfunction of any bodily
organ or part.
‘‘(e) QUALITY ASSURANCE PROGRAM.—
‘‘(1) IN GENERAL.—Each MedicarePlus organi-
zation must have arrangements, consistent with any
regulation, for an ongoing quality assurance pro-
gram for health care services it provides to individ-
uals enrolled with MedicarePlus plans of the organi-
zation.