‘‘(D) APPEAL TO SECRETARY.—Nothing in
this paragraph may be construed to replace or
supersede any appeals mechanism otherwise
provided for an individual entitled to benefits
under this title.
‘‘(4) NOTICE OF ENROLLEE RIGHTS AND EN-
ROLLEE INFORMATION CHECKLIST.—
‘‘(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 enrollee information checklist for the or-
ganization (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) ENROLLEE
INFORMATION
CHECK-
LIST.—For purposes of subparagraph (A), the
term ‘enrollee information checklist’ means,
with respect to an eligible organization for a
year, a list containing the following information
(provided in a manner that permits consumers
to compare organizations with respect to the in-
formation):
‘‘(i) For each plan, information 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, and
‘‘(VI) rights and responsibilities
of enrollees.
‘‘(ii) In addition, for each managed
care plan, information 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.
‘‘(5) 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.
‘‘(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—
‘‘(I) provides stop-loss protection
for the provider or group that is ade-
quate and appropriate, based on
standards developed by the Secretary
that take into account the number
(and type) of providers placed at such
substantial financial risk in the group
or under the plan and the number of
individuals enrolled with the organiza-
tion who receive services from the pro-
vider or the group, and
‘‘(II) conducts periodic surveys of
both individuals enrolled and individ-
uals previously enrolled with the orga-
nization to determine the degree of
access of such individuals to services
provided by the organization and sat-
isfaction with the quality of such serv-
ices.
‘‘(iii) The organization provides the
Secretary with descriptive information re-
garding the plan, sufficient to permit the
Secretary to determine whether the plan is
in compliance with the requirements of this
subparagraph.
‘‘(B) PROVIDER
INCENTIVE
PLAN
DE-
FINED.—In this paragraph, the term ‘provider
incentive plan’ means any compensation ar-
rangement between an eligible organization and
a provider or provider group that may directly
or indirectly have the effect of reducing or lim-
iting medically necessary services provided with
respect to individuals enrolled with the organi-
zation.
‘‘(6) PROHIBITION
OF
INTERFERENCE
WITH
CERTAIN MEDICAL COMMUNICATIONS.—