has a contractual or other arrangement with a man-
aged care plan may, upon request, provide an en-
rollee of the plan with a second opinion as to what
constitutes medically necessary and appropriate
treatment for the health of such enrollee.
(3) INSURANCE COVERAGE.—A managed care
plan must determine and pay a reasonable and ap-
propriate amount for a service determined, as de-
scribed in paragraphs (1) and (2), to be medically
necessary and appropriate if the service is covered
by the plan.
(g) REQUIREMENT FOR SERVICE TO AREAS THAT IN-
CLUDE A MEDICALLY UNDERSERVED POPULATION.—A
managed care plan seeking to provide services in an area
that includes a medically underserved population must
submit a plan to the Secretary outlining a proposal for
service to the medically underserved population.
(h) REQUIREMENT FOR MINIMUM NUMBER OF DOC-
TORS.—A managed care plan seeking to provide services
in an area must certify to the Secretary that the plan pro-
vides at least one physician for every 2,000 enrollees.
(i) DISCLOSURE OF FINANCIAL ARRANGEMENTS.—A
managed care plan shall disclose information to enrollees
on any financial arrangements which may restrict referral
or treatment options or limit the services offered by the
plan to such enrollees.
(j) REQUIREMENT FOR GEOGRAPHICAL ACCESSIBIL-
ITY.—A managed care plan shall ensure that items and
services (including laboratory and specialist services) cov-
ered under the plan shall be available through providers
that are geographically accessible to enrollees of such plan.
(k) MEANINGFUL CHOICE OF PROVIDERS.—A man-
aged care plan shall provide to enrollees a choice of at
least three providers within each category of providers
based on the health care needs of such enrollees, taking
into account the age, gender, health, native language,
acute or chronic diseases, and special needs.
(l) RIGHT TO SEEK CARE FROM OUT OF NETWORK
PROVIDER.—A managed care plan shall cover services cov-
ered by the plan that are furnished by a physician or pro-
vider obtained by the enrollee without regard to whether
such physician or provider has a contractual or other ar-
rangement with the plan for the provision of such services
to such enrollees. The plan may impose a reasonable de-
ductible and reasonable co-payment subject to a reason-
able annual limit on total annual out of pocket expenses.
(m) CONFIDENTIALITY OF INFORMATION.—A man-
aged care plan shall provide that information collected by
the plan on items and services used by the enrollees be
protected as confidential information.
(n) REQUIREMENT FOR GRIEVANCE PROCEDURES.—
Not later than 90 days after the date of the enactment
of this Act, the Health Care Financing Administration
shall establish complaint and grievance procedures for en-
rollees of managed care plans.
SEC. 3. ENFORCEMENT.
(a) IN GENERAL.—Any entity that offers a managed
care plan that violates a requirement of section 2 shall
be subject to a civil money penalty in an amount deter-
mined by the Secretary.
(b) PROCESS.—The provisions of section 1128A of
the Social Security Act (42 U.S.C. 1320a–7a) (other than
subsections (a) and (b)) shall apply to civil money pen-
alties under this section in the same manner as they apply
to a penalty or proceeding under section 1128A(a) of such
Act.
SEC. 4. REGULATIONS.
The Secretary shall promulgate such regulations as
may be necessary or appropriate to carry out this Act.
SEC. 5. DEFINITIONS.
For purposes of this Act:
(1) AREA.—The term ‘‘area’’ means the local
health–service area as designated in the managed
care plan of operations.
(2) EMERGENCY
DEPARTMENT.—The term
‘‘emergency department’’ includes, with respect to a
hospital, a trauma center in the hospital if the cen-
ter—
(A) is designated under section 1213 of
the Public Health Service Act, or
(B) is in a State that has not made such
designations and is determined by the Secretary
to meet the standards under such section for
such designation.
(3) EMERGENCY
MEDICAL
CONDITION.—The
term ‘‘emergency medical condition’’ means a medi-
cal condition, the onset of which is sudden, that
manifests itself by symptoms of sufficient severity,
including severe pain, that a prudent layperson, who
possesses an average knowledge of health and medi-
cine, could reasonably expect the absence of imme-
diate medical attention to result in—
(A) placing the person’s health in serious
jeopardy,
(B) serious impairment to bodily functions,
or
(C) serious dysfunction of any bodily organ
or part.
(4) EMERGENCY SERVICES.—The term ‘‘emer-
gency services’’ means—
(A) health care items and services fur-
nished in the emergency department of a hos-
pital, and
(B) ancillary services routinely available to
such department,
to the extent they are required to evaluate and treat
an emergency medical condition until the condition
is stabilized.
(5) LICENSED HEALTH CARE PRACTITIONER.—
The term ‘‘licensed health care practitioner’’ has the
meaning given such term in section 431(6) of the
Health Care Quality Improvement Act of 1986
(Public Law 99–660; 42 U.S.C. 11151(6)).
(6) MANAGED CARE PLAN.—The term ‘‘man-
aged care plan’’ means a health plan that provides
or arranges for the provision of health care items
and services to enrollees primarily through partici-
pating physicians and providers.
(7) MEDICALLY UNDERSERVED POPULATION.—
The term ‘‘medically underserved population’’ means
the population of an urban or rural area designated
by the Secretary as an area with a shortage of per-
sonal health services or a population group des-
ignated by the Secretary as having a shortage of
such services.
(8) PARTICIPATING.—The term ‘‘participating’’
means, with respect to a physician or provider in re-
lation to managed care, a physician or provider that
furnishes health care items and services to enrollees
of the plan under an agreement with the plan.
(9) SECRETARY.—The term ‘‘Secretary’’ means
of the Secretary of Health and Human Services.
(10) 
STABILIZED.—The 
term 
‘‘stabilized’’
means, with respect to an emergency medical condi-
tion, that no material deterioration of the condition
is likely, within reasonable medical probability, to re-
sult or occur before an individual can be transferred
in compliance with the requirements of section 1867
of the Social Security Act.
SEC. 6. EFFECTIVE DATE.
The provisions of this Act shall apply to managed
care plans offered or renewed 90-days after the date of
the enactment of this Act.
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