H. R. 2015—238
‘‘(b)(1) There is established in the Health Care Financing
Administration the position of Chief Actuary. The Chief Actuary
shall be appointed by, and in direct line of authority to, the Adminis-
trator of such Administration. The Chief Actuary shall be appointed
from among individuals who have demonstrated, by their education
and experience, superior expertise in the actuarial sciences. The
Chief Actuary shall exercise such duties as are appropriate for
the office of the Chief Actuary and in accordance with professional
standards of actuarial independence. The Chief Actuary may be
removed only for cause.
‘‘(2) The Chief Actuary shall be compensated at the highest
rate of basic pay for the Senior Executive Service under section
5382(b) of title 5, United States Code.’’.
SEC. 4644. CONFORMING AMENDMENTS TO COMPLY WITH CONGRES-
SIONAL REVIEW OF AGENCY RULEMAKING.
(a) DRG PROSPECTIVE PAYMENT RATE METHODOLOGY.—
(1) 
IN
GENERAL.—Section 
1886(d)(6) 
(42 
U.S.C.
1395ww(d)(6)) is amended by striking ‘‘September 1’’ and insert-
ing ‘‘August 1’’.
(2) TRANSITION RULE FOR FISCAL YEAR 1998.—With respect
to the publication in the Federal Register of the DRG prospec-
tive payment rate methodology under such section for fiscal
year 1998, the term ‘‘60 days’’ in section 801(a)(3)(A) and section
802(a) of title 5, United States Code, is deemed to be a reference
to ‘‘30 days’’.
(b) HOSPITAL PAYMENT UPDATES.—
(1) IN
GENERAL.—Section 1886(e) (42 U.S.C. 1395ww(e)
is amended—
(A) in paragraph (5)(A) by striking ‘‘May 1’’ and insert-
ing ‘‘April 1’’; and
(B) in paragraph (5)(B) by striking ‘‘September 1’’ and
inserting ‘‘August 1’’.
(2) TRANSITION RULE FOR FISCAL YEAR 1998.—With respect
to the publication in the Federal Register of the appropriate
change factor for inpatient hospital services for discharges in
fiscal year 1998 under section 1886(e)(5)(B) (42 U.S.C.
1395ww(e)(5)(B)), the term ‘‘60 days’’ in section 801(a)(3)(A)
and section 802(a) of title 5, United States Code, is deemed
to be a reference to ‘‘30 days’’.
(c) APPLICATIONS FOR GEOGRAPHIC RECLASSIFICATION.—
(1) 
IN
GENERAL.—Section 
1886(d)(10)(C) 
(42 
U.S.C.
1395ww(d)(10)(C)) is amended in clause (ii), by striking ‘‘the
first day of the preceding fiscal year.’’ and inserting ‘‘the first
day of the 13-month period ending on September 30 of the
preceding fiscal year.’’
(2) SPECIAL RULE FOR APPLICATIONS RECEIVED IN FISCAL
YEAR 1997.—In the case of an application for a change in
geographic classification under such section for fiscal year 1999,
the Secretary of Health and Human Services shall shorten
the deadlines under such section so as to permit completion
of a final decision by the Secretary by June 15, 1998.
(d) PHYSICIAN FEE SCHEDULE.—Section 1848(b)(1) (42 U.S.C.
1395w–4(b)(1)) is amended by striking ‘‘Before January 1 of each
year beginning with 1992’’ and inserting ‘‘Before November 1 of
the preceding year, for each year beginning with 1998’’.
H. R. 2015—239
Subtitle H—Medicaid
CHAPTER 1—MANAGED CARE
SEC. 4701. STATE OPTION OF USING MANAGED CARE; CHANGE IN
TERMINOLOGY.
(a) USE OF MANAGED CARE GENERALLY.—Title XIX is amended
by redesignating section 1932 as section 1933 and by inserting
after section 1931 the following new section:
‘‘PROVISIONS RELATING TO MANAGED CARE
‘‘SEC. 1932. (a) STATE OPTION TO USE MANAGED CARE.—
‘‘(1) USE OF MEDICAID MANAGED CARE ORGANIZATIONS AND
PRIMARY CARE CASE MANAGERS.—
‘‘(A) IN GENERAL.—Subject to the succeeding provisions
of this section, and notwithstanding paragraph (1), (10)(B),
or (23)(A) of section 1902(a), a State—
‘‘(i) may require an individual who is eligible for
medical assistance under the State plan under this
title to enroll with a managed care entity as a condition
of receiving such assistance (and, with respect to assist-
ance furnished by or under arrangements with such
entity, to receive such assistance through the entity),
if—
‘‘(I) the entity and the contract with the State
meet the applicable requirements of this section
and section 1903(m) or section 1905(t), and
‘‘(II) 
the 
requirements 
described 
in 
the
succeeding paragraphs of this subsection are met;
and
‘‘(ii) may restrict the number of provider agree-
ments with managed care entities under the State
plan if such restriction does not substantially impair
access to services.
‘‘(B) DEFINITION OF MANAGED CARE ENTITY.—In this
section, the term ‘managed care entity’ means—
‘‘(i) a medicaid managed care organization, as
defined in section 1903(m)(1)(A), that provides or
arranges for services for enrollees under a contract
pursuant to section 1903(m); and
‘‘(ii) a primary care case manager, as defined in
section 1905(t)(2).
‘‘(2) SPECIAL RULES.—
‘‘(A) EXEMPTION OF CERTAIN CHILDREN WITH SPECIAL
NEEDS.—A State may not require under paragraph (1) the
enrollment in a managed care entity of an individual under
19 years of age who—
‘‘(i) is eligible for supplemental security income
under title XVI;
‘‘(ii) is described in section 501(a)(1)(D);
‘‘(iii) is described in section 1902(e)(3);
‘‘(iv) is receiving foster care or adoption assistance
under part E of title IV; or
‘‘(v) is in foster care or otherwise in an out-of-
home placement.
H. R. 2015—240
‘‘(B) EXEMPTION OF MEDICARE BENEFICIARIES.—A State
may not require under paragraph (1) the enrollment in
a managed care entity of an individual who is a qualified
medicare beneficiary (as defined in section 1905(p)(1)) or
an individual otherwise eligible for benefits under title
XVIII.
‘‘(C) INDIAN ENROLLMENT.—A State may not require
under paragraph (1) the enrollment in a managed care
entity of an individual who is an Indian (as defined in
section 4(c) of the Indian Health Care Improvement Act
of 1976 (25 U.S.C. 1603(c)) unless the entity is one of
the following (and only if such entity is participating under
the plan):
‘‘(i) The Indian Health Service.
‘‘(ii) An Indian health program operated by an
Indian tribe or tribal organization pursuant to a con-
tract, grant, cooperative agreement, or compact with
the Indian Health Service pursuant to the Indian Self-
Determination Act (25 U.S.C. 450 et seq.).
‘‘(iii) An urban Indian health program operated
by an urban Indian organization pursuant to a grant
or contract with the Indian Health Service pursuant
to title V of the Indian Health Care Improvement
Act (25 U.S.C. 1601 et seq.).
‘‘(3) CHOICE OF COVERAGE.—
‘‘(A) IN GENERAL.—A State must permit an individual
to choose a managed care entity from not less than two
such entities that meet the applicable requirements of this
section, and of section 1903(m) or section 1905(t).
‘‘(B) STATE OPTION.—At the option of the State, a State
shall be considered to meet the requirements of subpara-
graph (A) in the case of an individual residing in a rural
area, if the State requires the individual to enroll with
a managed care entity if such entity—
‘‘(i) permits the individual to receive such assist-
ance through not less than two physicians or case
managers (to the extent that at least two physicians
or case managers are available to provide such assist-
ance in the area), and
(ii) permits the individual to obtain such assistance
from any other provider in appropriate circumstances
(as established by the State under regulations of the
Secretary).
‘‘(C) TREATMENT OF CERTAIN COUNTY-OPERATED HEALTH
INSURING ORGANIZATIONS.—A State shall be considered to
meet the requirement of subparagraph (A) if—
‘‘(i) the managed care entity in which the individ-
ual is enrolled is a health-insuring organization
which—
‘‘(I) first became operational prior to January
1, 1986, or
‘‘(II) is described in section 9517(c)(3) of the
Omnibus Budget Reconciliation Act of 1985 (as
added by section 4734(2) of the Omnibus Budget
Reconciliation Act of 1990), and
‘‘(ii) the individual is given a choice between at
least two providers within such entity.
H. R. 2015—241
‘‘(4) PROCESS
FOR
ENROLLMENT
AND
TERMINATION
AND
CHANGE
OF
ENROLLMENT.—As conditions under paragraph
(1)(A)—
‘‘(A) IN
GENERAL.—The State, enrollment broker (if
any), and managed care entity shall permit an individual
eligible for medical assistance under the State plan under
this title who is enrolled with the entity under this title
to terminate (or change) such enrollment—
‘‘(i) for cause at any time (consistent with section
1903(m)(2)(A)(vi)), and
‘‘(ii) without cause—
‘‘(I) during the 90-day period beginning on the
date the individual receives notice of such enroll-
ment, and
‘‘(II) at least every 12 months thereafter.
‘‘(B) NOTICE OF TERMINATION RIGHTS.—The State shall
provide for notice to each such individual of the opportunity
to terminate (or change) enrollment under such conditions.
Such notice shall be provided at least 60 days before each
annual enrollment opportunity described in subparagraph
(A)(ii)(II).
‘‘(C) ENROLLMENT PRIORITIES.—In carrying out para-
graph (1)(A), the State shall establish a method for
establishing enrollment priorities in the case of a managed
care entity that does not have sufficient capacity to enroll
all such individuals seeking enrollment under which
individuals already enrolled with the entity are given prior-
ity in continuing enrollment with the entity.
‘‘(D) DEFAULT ENROLLMENT PROCESS.—In carrying out
paragraph (1)(A), the State shall establish a default enroll-
ment process—
‘‘(i) under which any such individual who does
not enroll with a managed care entity during the
enrollment period specified by the State shall be
enrolled by the State with such an entity which has
not been found to be out of substantial compliance
with the applicable requirements of this section and
of section 1903(m) or section 1905(t); and
‘‘(ii) that takes into consideration—
‘‘(I) maintaining existing provider-individual
relationships or relationships with providers that
have traditionally served beneficiaries under this
title; and
‘‘(II) if maintaining such provider relationships
is not possible, the equitable distribution of such
individuals among qualified managed care entities
available to enroll such individuals, consistent with
the enrollment capacities of the entities.
‘‘(5) PROVISION OF INFORMATION.—
‘‘(A) INFORMATION IN EASILY UNDERSTOOD FORM.—Each
State, enrollment broker, or managed care entity shall
provide all enrollment notices and informational and
instructional materials relating to such an entity under
this title in a manner and form which may be easily under-
stood by enrollees and potential enrollees of the entity
who are eligible for medical assistance under the State
plan under this title.
H. R. 2015—242
‘‘(B) INFORMATION
TO
ENROLLEES
AND
POTENTIAL
ENROLLEES.—Each managed care entity that is a medicaid
managed care organization shall, upon request, make avail-
able to enrollees and potential enrollees in the organiza-
tion’s service area information concerning the following:
‘‘(i) PROVIDERS.—The identity, locations, qualifica-
tions, and availability of health care providers that
participate with the organization.
‘‘(ii) ENROLLEE RIGHTS AND RESPONSIBILITIES.—The
rights and responsibilities of enrollees.
‘‘(iii) GRIEVANCE
AND
APPEAL
PROCEDURES.—The
procedures available to an enrollee and a health care
provider to challenge or appeal the failure of the
organization to cover a service.
‘‘(iv) INFORMATION ON COVERED ITEMS AND SERV-
ICES.—All items and services that are available to
enrollees under the contract between the State and
the organization that are covered either directly or
through a method of referral and prior authorization.
Each managed care entity that is a primary care case
manager shall, upon request, make available to enroll-
ees and potential enrollees in the organization’s service
area the information described in clause (iii).
‘‘(C) 
COMPARATIVE
INFORMATION.—A 
State 
that
requires individuals to enroll with managed care entities
under paragraph (1)(A) shall annually (and upon request)
provide, directly or through the managed care entity, to
such individuals a list identifying the managed care entities
that are (or will be) available and information (presented
in a comparative, chart-like form) relating to the following
for each such entity offered:
‘‘(i) BENEFITS
AND
COST-SHARING.—The benefits
covered and cost-sharing imposed by the entity.
‘‘(ii) SERVICE AREA.—The service area of the entity.
‘‘(iii) QUALITY AND PERFORMANCE.—To the extent
available, quality and performance indicators for the
benefits under the entity.
‘‘(D) INFORMATION ON BENEFITS NOT COVERED UNDER
MANAGED
CARE
ARRANGEMENT.—A State, directly or
through managed care entities, shall, on or before an
individual enrolls with such an entity under this title,
inform the enrollee in a written and prominent manner
of any benefits to which the enrollee may be entitled to
under this title but which are not made available to the
enrollee through the entity. Such information shall include
information on where and how such enrollees may access
benefits not made available to the enrollee through the
entity.’’.
(b) CHANGE IN TERMINOLOGY.—
(1) 
IN
GENERAL.—Section 
1903(m)(1)(A) 
(42 
U.S.C.
1396b(m)) is amended—
(A) by striking ‘‘The term’’ and all that follows through
‘‘and—’’ and inserting ‘‘The term ‘medicaid managed care
organization’ means a health maintenance organization,
an eligible organization with a contract under section 1876
or a Medicare+Choice organization with a contract under
part C of title XVIII, a provider sponsored organization,
H. R. 2015—244
(i) by striking ‘‘except as provided under subpara-
graph (F),’’,
(ii) by striking ‘‘without cause’’ and all that follows
through ‘‘for such termination’’ and inserting ‘‘in
accordance with section 1932(a)(4);’’,
(iii) by inserting ‘‘in accordance with such section’’
after ‘‘provides for notification’’; and
(B) by striking subparagraph (F).
SEC. 4702. PRIMARY CARE CASE MANAGEMENT SERVICES AS STATE
OPTION WITHOUT NEED FOR WAIVER.
(a) IN GENERAL.—Section 1905 (42 U.S.C. 1396d) is amended—
(1) in subsection (a)—
(A) by striking ‘‘and’’ at the end of paragraph (24);
(B) by redesignating paragraph (25) as paragraph (26)
and by striking the period at the end of such paragraph
and inserting a comma; and
(C) by inserting after paragraph (24) the following
new paragraph:
‘‘(25) primary care case management services (as defined
in subsection (t)); and’’; and
(2) by adding at the end the following new subsection:
‘‘(t)(1) The term ‘primary care case management services’ means
case-management related services (including locating, coordinating,
and monitoring of health care services) provided by a primary
care case manager under a primary care case management contract.
‘‘(2) The term ‘primary care case manager’ means any of the
following that provides services of the type described in paragraph
(1) under a contract referred to in such paragraph:
‘‘(A) A physician, a physician group practice, or an entity
employing or having other arrangements with physicians to
provide such services.
‘‘(B) At State option—
‘‘(i) a nurse practitioner (as described in section
1905(a)(21));
‘‘(ii) a certified nurse-midwife (as defined in section
1861(gg)); or
‘‘(iii) a physician assistant (as defined in section
1861(aa)(5)).
‘‘(3) The term ‘primary care case management contract’ means
a contract between a primary care case manager and a State
under which the manager undertakes to locate, coordinate, and
monitor covered primary care (and such other covered services
as may be specified under the contract) to all individuals enrolled
with the manager, and which—
‘‘(A) provides for reasonable and adequate hours of oper-
ation, including 24-hour availability of information, referral,
and treatment with respect to medical emergencies;
‘‘(B) restricts enrollment to individuals residing sufficiently
near a service delivery site of the manager to be able to reach
that site within a reasonable time using available and afford-
able modes of transportation;
‘‘(C) provides for arrangements with, or referrals to, suffi-
cient numbers of physicians and other appropriate health care
professionals to ensure that services under the contract can
be furnished to enrollees promptly and without compromise
to quality of care;
H. R. 2015—245
‘‘(D) prohibits discrimination on the basis of health status
or requirements for health care services in enrollment,
disenrollment, or reenrollment of individuals eligible for medi-
cal assistance under this title;
‘‘(E) provides for a right for an enrollee to terminate enroll-
ment in accordance with section 1932(a)(4); and
‘‘(F) complies with the other applicable provisions of section
1932.
‘‘(4) For purposes of this subsection, the term ‘primary care’
includes all health care services customarily provided in accordance
with State licensure and certification laws and regulations, and
all laboratory services customarily provided by or through, a general
practitioner, family medicine physician, internal medicine physician,
obstetrician/gynecologist, or pediatrician.’’.
(b) CONFORMING AMENDMENTS.—
(1) APPLICATION OF REENROLLMENT PROVISIONS TO PCCMS.—
Section 1903(m)(2)(H) (42 U.S.C. 1396b(m)(2)(H)) is amended—
(A) in clause (i), by inserting before the comma the
following: ‘‘or with a primary care case manager with a
contract described in section 1905(t)(3)’’; and
(B) by inserting before the period at the end the follow-
ing: ‘‘or with the manager described in such clause if the
manager continues to have a contract described in section
1905(t)(3) with the State’’.
(2) CONFORMING
CROSS-REFERENCE.—Section 1902(j) (42
U.S.C. 1396a(j)) is amended by striking ‘‘paragraphs (1) through
(25)’’ and inserting ‘‘a numbered paragraph of’’.
SEC. 4703. ELIMINATION OF 75:25 RESTRICTION ON RISK CONTRACTS.
(a) 
IN
GENERAL.—Section 
1903(m)(2)(A) 
(42 
U.S.C.
1396b(m)(2)(A)) is amended by striking clause (ii).
(b) CONFORMING AMENDMENTS.—
(1) Section 1903(m)(2) (42 U.S.C. 1396b(m)(2)) is amend-
ed—
(A) by striking subparagraphs (C), (D), and (E); and
(B) in subparagraph (G), by striking ‘‘clauses (i) and
(ii)’’ and inserting ‘‘clause (i)’’.
(2) Section 1925(b)(4)(D)(iv) (42 U.S.C. 1396r–6(b)(4)(D)(iv))
is amended by striking ‘‘less than 50 percent’’ and all that
follows up to the period at the end.
SEC. 4704. INCREASED BENEFICIARY PROTECTIONS.
(a) IN GENERAL.—Section 1932, as added by section 4701(a),
is amended by adding at the end the following:
‘‘(b) BENEFICIARY PROTECTIONS.—
‘‘(1) SPECIFICATION
OF
BENEFITS.—Each contract with a
managed care entity under section 1903(m) or under section
1905(t)(3) shall specify the benefits the provision (or arrange-
ment) for which the entity is responsible.
‘‘(2) ASSURING COVERAGE TO EMERGENCY SERVICES.—
‘‘(A) IN GENERAL.—Each contract with a medicaid man-
aged care organization under section 1903(m) and each
contract with a primary care case manager under section
1905(t)(3) shall require the organization or manager—
‘‘(i) to provide coverage for emergency services (as
defined in subparagraph (B)) without regard to prior
H. R. 2015—246
authorization or the emergency care provider’s contrac-
tual relationship with the organization or manager,
and
‘‘(ii) to comply with guidelines established under
section 1852(d)(2) (respecting coordination of post-sta-
bilization care) in the same manner as such guidelines
apply to Medicare+Choice plans offered under part C
of title XVIII.
The requirement under clause (ii) shall first apply 30 days
after the date of promulgation of the guidelines referred
to in such clause.
‘‘(B) EMERGENCY SERVICES DEFINED.—In subparagraph
(A)(i), 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 stabilize an emer-
gency medical condition (as defined in subparagraph
(C)).
‘‘(C) EMERGENCY
MEDICAL
CONDITION
DEFINED.—In
subparagraph (B)(ii), the term ‘emergency medical condi-
tion’ means a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such
that a prudent layperson, who possesses an average knowl-
edge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in—
‘‘(i) placing the health of the individual (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.
‘‘(3) PROTECTION
OF
ENROLLEE-PROVIDER
COMMUNICA-
TIONS.—
‘‘(A) IN GENERAL.—Subject to subparagraphs (B) and
(C), under a contract under section 1903(m) a medicaid
managed care organization (in relation to an individual
enrolled under the contract) shall not prohibit or otherwise
restrict a covered health care professional (as defined in
subparagraph (D)) from advising such an individual who
is a patient of the professional about the health status
of the individual or medical care or treatment for the
individual’s condition or disease, regardless of whether
benefits for such care or treatment are provided under
the contract, if the professional is acting within the lawful
scope of practice.
‘‘(B) CONSTRUCTION.—Subparagraph (A) shall not be
construed as requiring a medicaid managed care organiza-
tion to provide, reimburse for, or provide coverage of, a
counseling or referral service if the organization—
‘‘(i) objects to the provision of such service on moral
or religious grounds; and
‘‘(ii) in the manner and through the written
instrumentalities such organization deems appropriate,
makes available information on its policies regarding
such service to prospective enrollees before or during
H. R. 2015—247
enrollment and to enrollees within 90 days after the
date that the organization adopts a change in policy
regarding such a counseling or referral service.
Nothing in this subparagraph shall be construed to affect
disclosure requirements under State law or under the
Employee Retirement Income Security Act of 1974.
‘‘(C) HEALTH CARE PROFESSIONAL DEFINED.—For pur-
poses of this paragraph, the term ‘health care professional’
means a physician (as defined in section 1861(r)) or other
health care professional if coverage for the professional’s
services is provided under the contract referred to in
subparagraph (A) for the services of the professional. Such
term includes a podiatrist, optometrist, chiropractor,
psychologist, dentist, physician assistant, physical or
occupational therapist and therapy assistant, speech-lan-
guage pathologist, audiologist, registered or licensed prac-
tical nurse (including nurse practitioner, clinical nurse
specialist, certified registered nurse anesthetist, and cer-
tified nurse-midwife), licensed certified social worker, reg-
istered respiratory therapist, and certified respiratory ther-
apy technician.
‘‘(4) GRIEVANCE
PROCEDURES.—Each medicaid managed
care organization shall establish an internal grievance proce-
dure under which an enrollee who is eligible for medical assist-
ance under the State plan under this title, or a provider on
behalf of such an enrollee, may challenge the denial of coverage
of or payment for such assistance.
‘‘(5) DEMONSTRATION
OF
ADEQUATE
CAPACITY
AND
SERV-
ICES.—Each medicaid managed care organization shall provide
the State and the Secretary with adequate assurances (in a
time and manner determined by the Secretary) that the
organization, with respect to a service area, has the capacity
to serve the expected enrollment in such service area, including
assurances that the organization—
‘‘(A) offers an appropriate range of services and access
to preventive and primary care services for the population
expected to be enrolled in such service area, and
‘‘(B) 
maintains 
a 
sufficient 
number, 
mix, 
and
geographic distribution of providers of services.
‘‘(6) PROTECTING ENROLLEES AGAINST LIABILITY FOR PAY-
MENT.—Each medicaid managed care organization shall provide
that an individual eligible for medical assistance under the
State plan under this title who is enrolled with the organization
may not be held liable—
‘‘(A) for the debts of the organization, in the event
of the organization’s insolvency,
‘‘(B) for services provided to the individual—
‘‘(i) in the event of the organization failing to
receive payment from the State for such services; or
‘‘(ii) in the event of a health care provider with
a contractual, referral, or other arrangement with the
organization failing to receive payment from the State
or the organization for such services, or
‘‘(C) for payments to a provider that furnishes covered
services under a contractual, referral, or other arrangement
with the organization in excess of the amount that would