I 
113TH CONGRESS 
2D SESSION 
H. R. 4998 
To enhance beneficiary and provider protections and improve transparency 
in the Medicare Advantage market, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JUNE 26, 2014 
Ms. DELAURO introduced the following bill; which was referred to the Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned 
A BILL 
To enhance beneficiary and provider protections and improve 
transparency in the Medicare Advantage market, and 
for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicare Advantage 
Participant Bill of Rights Act of 2014’’. 
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SEC. 2. LIMITATION ON REMOVAL OF MEDICARE ADVAN-
TAGE PROVIDERS BY MA ORGANIZATIONS. 
(a) LIMITATION.—Section 1852(d) of the Social Se-
curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 
at the end the following: 
‘‘(7) LIMITATION ON REMOVAL OF PROVIDERS 
FROM MA PLANS BY MA ORGANIZATIONS.— 
‘‘(A) REMOVAL
OF
PROVIDERS
WITH 
CAUSE.—Beginning with plan year 2015, except 
as provided in subparagraph (C), an MA orga-
nization offering an MA plan may only remove 
a provider of services or a supplier from a net-
work of such plan if the organization has cause 
to remove such provider or supplier. 
‘‘(B) CAUSE TO REMOVE PROVIDERS.— 
‘‘(i) IN GENERAL.—An MA organiza-
tion offering an MA plan has cause to re-
move a provider of services or a supplier 
from a network of such plan if the Sec-
retary determines that the provider or sup-
plier is— 
‘‘(I) medically negligent; 
‘‘(II) in violation of any legal or 
contractual requirement applicable to 
the provider or supplier acting within 
the lawful scope of practice, including 
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any participation or other requirement 
applicable to such provider or supplier 
under this title or under any contrac-
tual term for such plan; or 
‘‘(III) otherwise unfit to furnish 
items and services in accordance with 
requirements of this title. 
‘‘(ii) CONSIDERATION OF COST TO MA 
ORGANIZATIONS.—For purposes of sub-
paragraph (A), cost to an MA organization 
offering an MA plan due to the participa-
tion of a provider of services or supplier in 
a network of such plan does not constitute 
cause for the MA organization to remove 
such provider or supplier from the net-
work, and such cost may not be considered 
as a factor in favor of a determination that 
such organization has cause to remove the 
provider. 
‘‘(C) EXCEPTION.—With respect to each 
upcoming plan year, beginning with plan year 
2015, an MA organization offering an MA plan 
may only remove a provider of services or sup-
plier from a network of such plan for reasons 
not specified in subparagraph (B)(i) before the 
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date that is 60 days before the first day of the 
annual coordinated election period for such plan 
year under section 1851(e)(3). 
‘‘(D) NOTICE AND APPEAL PROCESS.— 
‘‘(i) IN GENERAL.—Any removal of a 
provider of services or supplier from a net-
work of an MA plan may occur only after 
the completion of a fair notice and appeal 
process that the Secretary shall establish 
by regulation. Such process shall require 
the MA organization to provide to such 
provider or supplier and to the Secretary 
an explanation of the reason or reasons for 
the removal. 
‘‘(ii) APPLICATION.— 
‘‘(I) APPLICATION OF NEW PROC-
ESS.—In the case of a removal of a 
provider of services or supplier from a 
network of an MA plan occurring on 
or after the effective date published in 
a final rule for such fair notice and 
appeal process, such process shall 
apply in lieu of the process for the 
termination or suspension of a pro-
vider 
contract 
under 
section 
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422.202(a) of title 42, Code of Fed-
eral Regulations. 
‘‘(II) CONTINUATION
OF
OLD 
PROCESS.—In the case of a removal of 
a provider of services or supplier from 
a network of an MA plan occurring 
before such effective date, the process 
for the termination or suspension of a 
provider 
contract 
under 
section 
422.202(a) of title 42, Code of Fed-
eral Regulations, shall apply. 
‘‘(E) PARTICIPANT NOTICE AND PROTEC-
TION.— 
‘‘(i) NOTICE
TO
PARTICIPANTS
OF 
PROVIDER
REMOVAL.—Not less than 60 
days before the date on which a provider 
of services or supplier is removed from a 
network of an MA plan, the MA organiza-
tion offering such plan shall provide notifi-
cation of the removal to each individual en-
rolled in such plan receiving items or serv-
ices from the provider or supplier during 
the plan year in effect on the date of re-
moval or during the previous plan year. 
Such notification shall include— 
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‘‘(I) the names and telephone 
numbers of in-network providers of 
services and suppliers offering items 
and services that are the same or 
similar to the items and services of-
fered by the removed provider or sup-
plier; 
‘‘(II) information regarding the 
options available to an individual en-
rolled in such plan to request the con-
tinuation of medical treatment or 
therapy with the removed provider or 
supplier; and 
‘‘(III) one or more customer serv-
ice telephone numbers that an indi-
vidual enrolled in such plan may ac-
cess to obtain information regarding 
changes to the network of the plan. 
‘‘(ii) ANNUAL NOTICE OF CHANGE.— 
In addition to providing the notification of 
removal as required under clause (i), the 
MA organization offering such MA plan 
shall include such notification in the an-
nual notice of change for the MA plan for 
the upcoming plan year. 
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‘‘(iii) CONTINUITY OF CARE.—In any 
case in which a provider of services or sup-
plier is removed from a network of an MA 
plan, such plan shall ensure that the re-
moval satisfies the continuity of care re-
quirements under paragraph (1)(A) with 
respect to each individual enrolled in such 
plan receiving items or services from the 
provider or supplier during the plan year 
in effect on the date of removal or during 
the previous plan year. 
‘‘(F) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as affect-
ing the ability of a provider of services or sup-
plier to decline to participate in a network of an 
MA plan. 
‘‘(8) TRANSPARENCY IN MEASURES USED BY 
MA ORGANIZATIONS TO ESTABLISH OR MODIFY PRO-
VIDER NETWORKS.— 
‘‘(A) IN GENERAL.—Beginning with plan 
year 2016, an MA organization offering an MA 
plan shall include the information described in 
subparagraph (B)— 
‘‘(i) in the annual bid information 
submitted by the MA organization with re-
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spect to the MA plan under section 1854; 
and 
‘‘(ii) on the Internet Web site for the 
MA plan. 
‘‘(B) INFORMATION DESCRIBED.—The in-
formation described in this subparagraph is the 
following: 
‘‘(i) Information regarding the meas-
ures used by the MA organization to estab-
lish or modify the provider network of the 
MA plan, including measures of the quality 
and efficiency of providers. Such informa-
tion shall include the specifications, meth-
odology, and sample size of such measures. 
‘‘(ii) Other information related to the 
establishment or modification of such pro-
vider network that the Secretary deter-
mines appropriate. 
‘‘(C) LIMITATION.—The information de-
scribed in subparagraph (B) shall not include 
any individually identifiable information of any 
provider or supplier of services.’’. 
(b) ENFORCEMENT.— 
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(1) SANCTIONS FOR NONCOMPLIANCE.—Section 
1857(g)(1) of the Social Security Act (42 U.S.C. 
1395w–27(g)(1)) is amended— 
(A) in subparagraph (J), by striking ‘‘or’’; 
(B) by redesignating subparagraph (K) as 
subparagraph (L); 
(C) by inserting after subparagraph (J) 
the following new subparagraph: 
‘‘(K) 
fails 
to 
comply 
with 
sections 
1852(d)(7) or 1852(d)(8); or’’; and 
(D) in subparagraph (L) (as so redesig-
nated), by striking ‘‘through (J)’’ and inserting 
‘‘through (K)’’. 
(2) SANCTIONS NOT APPLICABLE TO PART D.— 
Title XVIII of the Social Security Act is amended— 
(A) in section 1860D–12(b)(3)(E) (42 
U.S.C. 
1395w–112(b)(3)(E)), 
by 
striking 
‘‘paragraph (1)(F)’’ and inserting ‘‘paragraphs 
(1)(F) and (1)(K)’’; and 
(B) in section 1894(e)(6)(B) (42 U.S.C. 
1395eee(e)(6)(B)), by inserting ‘‘(other than 
paragraph (1)(K) of such section)’’ after 
‘‘1857(g)(1)’’. 
(c) NETWORK ACCESS ADEQUACY STANDARDS.—Be-
ginning with plan year 2015, in applying the network ac-
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cess adequacy standards pursuant to section 1852(d)(1) 
of the Social Security Act (42 U.S.C. 1395w–22(d)(1)), 
the Secretary of Health and Human Services shall seek 
input from patient advocacy groups, providers of services 
and suppliers, and MA plans under part C of title XVIII 
of such Act. 
(d) MEDICARE ADVANTAGE PLAN COMPARE TOOL.— 
Not later than September 30, 2015, the Secretary of 
Health and Human Services shall take such measures as 
are necessary to ensure that the Medicare Advantage 
Compare Tool takes into account the preferences and utili-
zation needs of such individuals. 
Æ 
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