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1905(p)(1)) or an individual otherwise eligible for
benefits under title XVIII.
‘‘(f) RULE OF CONSTRUCTION.—Nothing in this part
shall be construed as allowing a managed care entity that
has entered into a contract with the State under this part
to restrict the choice of an individual in receiving services
described in section 1905(a)(4)(C).
‘‘SEC. 1942. BENEFICIARY ACCESS TO SERVICES GEN-
ERALLY.
‘‘(a) ACCESS TO SERVICES.—
‘‘(1) IN GENERAL.—Each managed care entity
shall provide or arrange for the provision of all medi-
cally necessary medical assistance under this title
which is specified in the contract entered into between
such entity and the State under section 1941(a)(1)(B)
for enrollees who are eligible for medical assistance
under the State plan under this title.
‘‘(2) 
PRIMARY-CARE-PROVIDER-TO-ENROLLEE
RATIO AND MAXIMUM TRAVEL TIME.—Each such en-
tity shall assure adequate access to primary care serv-
ices by meeting standards, established by the Sec-
retary, relating to the maximum ratio of enrollees
under this title to full-time-equivalent primary care
providers available to serve such enrollees and to
maximum travel time for such enrollees to access such
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HR 2015 EAS
providers. The Secretary may permit such a maxi-
mum ratio to vary depending on the area and popu-
lation served. Such standards shall be based on stand-
ards commonly applied in the commercial market,
commonly used in accreditation of managed care or-
ganizations, and standards used in the approval of
waiver applications under section 1115, and shall be
consistent 
with 
the 
requirements 
of 
section
1876(c)(4)(A) and part C of title XVIII.
‘‘(b) REFERRAL TO SPECIALTY CARE FOR ENROLLEES
REQUIRING TREATMENT BY SPECIALISTS.—
‘‘(1) IN GENERAL.—In the case of an enrollee
under a managed care entity and who has a condi-
tion or disease of sufficient seriousness and complex-
ity to require treatment by a specialist, the entity
shall make or provide for a referral to a specialist
who is available and accessible to provide the treat-
ment for such condition or disease.
‘‘(2) SPECIALIST DEFINED.—For purposes of this
subsection, the term ‘specialist’ means, with respect to
a condition, a health care practitioner, facility, or
center (such as a center of excellence) that has ade-
quate expertise through appropriate training and ex-
perience (including, in the case of a child, an appro-
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HR 2015 EAS
priate pediatric specialist) to provide high quality
care in treating the condition.
‘‘(3) CARE
UNDER
REFERRAL.—Care provided
pursuant to such referral under paragraph (1) shall
be—
‘‘(A) pursuant to a treatment plan (if any)
developed by the specialist and approved by the
entity, in consultation with the designated pri-
mary care provider or specialist and the enrollee
(or the enrollee’s designee), and
‘‘(B) in accordance with applicable quality
assurance and utilization review standards of
the entity.
Nothing in this subsection shall be construed as pre-
venting such a treatment plan for an enrollee from re-
quiring a specialist to provide the primary care pro-
vider with regular updates on the specialty care pro-
vided, as well as all necessary medical information.
‘‘(4) REFERRALS
TO
PARTICIPATING
PROVID-
ERS.—An entity is not required under paragraph (1)
to provide for a referral to a specialist that—
‘‘(A) is not a participating provider, unless
the entity does not have an appropriate special-
ist that is available and accessible to treat the
enrollee’s condition, and
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HR 2015 EAS
‘‘(B) is a participating provider with re-
spect to such treatment.
‘‘(5) TREATMENT OF NONPARTICIPATING PROVID-
ERS.—If an entity refers an enrollee to a nonpartici-
pating specialist, services provided pursuant to the
approved treatment plan shall be provided at no ad-
ditional cost to the enrollee beyond what the enrollee
would otherwise pay for services received by such a
specialist that is a participating provider.
‘‘(c) TIMELY DELIVERY OF SERVICES.—Each managed
care entity shall respond to requests from enrollees for the
delivery of medical assistance in a manner which—
‘‘(1) makes such assistance—
‘‘(A) available and accessible to each such
individual, within the area served by the entity,
with reasonable promptness and in a manner
which assures continuity; and
‘‘(B) when medically necessary, available
and accessible 24 hours a day and 7 days a
week, and
‘‘(2) with respect to assistance provided to such
an individual other than through the entity, or with-
out prior authorization, in the case of a primary care
case manager, provides for reimbursement to the indi-
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HR 2015 EAS
vidual (if applicable under the contract between the
State and the entity) if—
‘‘(A) the services were medically necessary
and immediately required because of an unfore-
seen illness, injury, or condition and meet the re-
quirements for access to emergency care under
section 1943; and
‘‘(B) it was not reasonable given the cir-
cumstances to obtain the services through the en-
tity, or, in the case of a primary care case man-
ager, with prior authorization.
‘‘(d) INTERNAL GRIEVANCE PROCEDURE.—Each med-
icaid managed care organization shall establish an internal
grievance procedure under which an enrollee who is eligible
for medical assistance 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.
‘‘(e) INFORMATION ON BENEFIT CARVE OUTS.—Each
managed care entity shall inform each enrollee, in a written
and prominent manner, of any benefits to which the enrollee
may be entitled to medical assistance 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.
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‘‘(f) DEMONSTRATION OF ADEQUATE CAPACITY AND
SERVICES.—Each medicaid managed care organization
shall provide the State and the Secretary with adequate as-
surances (as determined by the Secretary) that the organi-
zation, with respect to a service area—
‘‘(1) has the capacity to serve the expected enroll-
ment in such service area,
‘‘(2) offers an appropriate range of services for
the population expected to be enrolled in such service
area, including transportation services and trans-
lation services consisting of the principal languages
spoken in the service area,
‘‘(3) maintains a sufficient number, mix, and ge-
ographic distribution of providers of services included
in the contract with the State to ensure that services
are available to individuals receiving medical assist-
ance and enrolled in the organization to the same ex-
tent that such services are available to individuals en-
rolled in the organization who are not recipients of
medical assistance under the State plan under this
title,
‘‘(4) maintains extended hours of operation with
respect to primary care services that are beyond those
maintained during a normal business day,
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‘‘(5) provides preventive and primary care serv-
ices in locations that are readily accessible to mem-
bers of the community,
‘‘(6) 
provides 
information 
concerning 
edu-
cational, social, health, and nutritional services of-
fered by other programs for which enrollees may be el-
igible, and
‘‘(7) complies with such other requirements relat-
ing to access to care as the Secretary or the State
may impose.
‘‘(g) COMPLIANCE WITH CERTAIN MATERNITY AND
MENTAL HEALTH REQUIREMENTS.—Each medicaid man-
aged care organization shall comply with the requirements
of subpart 2 of part A of title XXVII of the Public Health
Service Act insofar as such requirements apply with respect
to a health insurance issuer that offers group health insur-
ance coverage.
‘‘(h) TREATMENT
OF
CHILDREN
WITH
SPECIAL
HEALTH CARE NEEDS.—
‘‘(1) IN GENERAL.—In the case of an enrollee of
a managed care entity who is a child described in sec-
tion 1941(e)(1)—
‘‘(A) if any medical assistance specified in
the contract with the State is identified in a
treatment plan prepared for the enrollee, the
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managed care entity shall provide (or arrange to
be provided) such assistance in accordance with
the treatment plan either—
‘‘(i) by referring the enrollee to a pedi-
atric health care provider who is trained
and experienced in the provision of such as-
sistance and who has a contract with the
managed care entity to provide such assist-
ance; or
‘‘(ii) if appropriate services are not
available through the managed care entity,
permitting such enrollee to seek appropriate
specialty services from pediatric health care
providers outside of or apart from the man-
aged care entity, and
‘‘(B) the managed care entity shall require
each health care provider with whom the man-
aged care entity has entered into an agreement
to provide medical assistance to enrollees to fur-
nish the medical assistance specified in such en-
rollee’s treatment plan to the extent the health
care provider is able to carry out such treatment
plan.
‘‘(2) PRIOR
AUTHORIZATION.—An enrollee re-
ferred for treatment under paragraph (1)(A)(i), or
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HR 2015 EAS
permitted to seek treatment outside of or apart from
the managed care entity under paragraph (1)(A)(ii)
shall be deemed to have obtained any prior authoriza-
tion required by the entity.
‘‘SEC. 1943. REQUIREMENTS FOR ACCESS TO EMERGENCY
CARE.
‘‘(a) IN GENERAL.—A managed care entity shall—
‘‘(1) provide coverage for emergency services (as
defined in subsection (c)) without regard to prior au-
thorization or the emergency care provider’s contrac-
tual relationship with the organization; and
‘‘(2) comply with such guidelines as the Sec-
retary shall prescribe relating to promoting efficient
and timely coordination of appropriate maintenance
and post-stabilization care of an enrollee after the en-
rollee has been determined to be stable in accordance
with section 1867.
‘‘(b) CONTENT OF GUIDELINES.—The guidelines pre-
scribed under subsection (a) shall provide that—
‘‘(1) a provider of emergency services shall make
a documented good faith effort to contact the managed
care entity in a timely fashion from the point at
which the individual is stabilized to request approval
for medically necessary post-stabilization care,
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‘‘(2) the entity shall respond in a timely fashion
to the initial contact with the entity with a decision
as to whether the services for which approval is re-
quested will be authorized, and
‘‘(3) if a denial of a request is communicated,
the entity shall, upon request from the treating physi-
cian, arrange for a physician who is authorized by
the entity to review the denial to communicate di-
rectly with the treating physician in a timely fashion.
‘‘(c) DEFINITION OF EMERGENCY SERVICES.—In this
section—
‘‘(1) IN GENERAL.—The term ‘emergency serv-
ices’ means, with respect to an individual enrolled
with a managed care entity, covered inpatient and
outpatient services that—
‘‘(A) are furnished by a provider that is
qualified to furnish such services under this title,
and
‘‘(B) are needed to evaluate or stabilize an
emergency medical condition (as defined in sub-
paragraph (B)).
‘‘(2) EMERGENCY MEDICAL CONDITION BASED ON
PRUDENT LAYPERSON.—The term ‘emergency medical
condition’ means a medical condition manifesting it-
self by acute symptoms of sufficient severity (includ-
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HR 2015 EAS
ing severe pain) such that a prudent layperson, who
possesses an average knowledge of health and medi-
cine, could reasonably expect the absence of immediate
medical attention to result in—
‘‘(A) placing the health of the individual
(or, with respect to a pregnant woman, the
health of the woman or her unborn child) in seri-
ous jeopardy,
‘‘(B) serious impairment to bodily func-
tions, or
‘‘(C) serious dysfunction of any bodily
organ or part.
‘‘SEC. 1944. OTHER BENEFICIARY PROTECTIONS.
‘‘(a) PROTECTING ENROLLEES AGAINST THE INSOL-
VENCY OF MANAGED CARE ENTITIES AND AGAINST THE
FAILURE OF THE STATE TO PAY SUCH ENTITIES.—Each
managed care entity shall provide that an individual eligi-
ble for medical assistance under the State plan under this
title who is enrolled with the entity may not be held liable—
‘‘(1) for the debts of the managed care entity, in
the event of the entity’s insolvency,
‘‘(2) for services provided to the individual—
‘‘(A) in the event of the entity failing to re-
ceive payment from the State for such services;
or
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HR 2015 EAS
‘‘(B) in the event of a health care provider
with a contractual or other arrangement with
the entity failing to receive payment from the
State or the managed care entity for such serv-
ices, or
‘‘(3) for the debts of any health care provider
with a contractual or other arrangement with the en-
tity to provide services to the individual, in the event
of the insolvency of the health care provider.
‘‘(b) PROTECTION OF BENEFICIARIES AGAINST BAL-
ANCE BILLING THROUGH SUBCONTRACTORS.—
‘‘(1) IN
GENERAL.—Any contract between a
managed care entity that has an agreement with a
State under this title and another entity under which
the other entity (or any other entity pursuant to the
contract) provides directly or indirectly for the provi-
sion of services to beneficiaries under the agreement
with the State shall include such provisions as the
Secretary may require in order to assure that the
other entity complies with balance billing limitations
and other requirements of this title (such as limita-
tion on withholding of services) as they would apply
to the managed care entity if such entity provided
such services directly and not through a contract with
another entity.
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HR 2015 EAS
‘‘(2) APPLICATION
OF
SANCTIONS
FOR
VIOLA-
TIONS.—The provisions of section 1128A(b)(2)(B) and
1128B(d)(1) shall apply with respect to entities con-
tracting directly or indirectly with a managed care
entity (with a contract with a State under this title)
for the provision of services to beneficiaries under
such a contract in the same manner as such provi-
sions would apply to the managed care entity if it
provided such services directly and not through a con-
tract with another entity.
‘‘SEC. 1945. ASSURING QUALITY CARE.
‘‘(a) EXTERNAL INDEPENDENT REVIEW OF MANAGED
CARE ENTITY ACTIVITIES.—
‘‘(1) REVIEW OF MEDICAID MANAGED CARE OR-
GANIZATION CONTRACT.—
‘‘(A) IN GENERAL.—Except as provided in
paragraph (2), each medicaid managed care or-
ganization shall be subject to an annual external
independent review of the quality outcomes and
timeliness of, and access to, the items and serv-
ices specified in such organization’s contract
with the State under section 1941(a)(1)(B). Such
review shall specifically evaluate the extent to
which the medicaid managed care organization
provides such services in a timely manner.
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HR 2015 EAS
‘‘(B) CONTENTS OF REVIEW.—An external
independent review conducted under this sub-
section shall include—
‘‘(i) a review of the entity’s medical
care, through sampling of medical records
or other appropriate methods, for indica-
tions of quality of care and inappropriate
utilization (including overutilization) and
treatment,
‘‘(ii) a review of enrollee inpatient and
ambulatory data, through sampling of med-
ical records or other appropriate methods,
to determine trends in quality and appro-
priateness of care,
‘‘(iii) notification of the entity and the
State when the review under this paragraph
indicates inappropriate care, treatment, or
utilization of services (including overutili-
zation), and
‘‘(iv) other activities as prescribed by
the Secretary or the State.
‘‘(C) USE
OF
PROTOCOLS.—An external
independent review conducted under this sub-
section on and after January 1, 1999, shall use
protocols that have been developed, tested, and
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HR 2015 EAS
validated by the Secretary and that are at least
as rigorous as those used by the National Com-
mittee on Quality Assurance as of the date of the
enactment of this section.
‘‘(D) AVAILABILITY OF RESULTS.—The re-
sults of each external independent review con-
ducted under this paragraph shall be available to
participating health care providers, enrollees,
and potential enrollees of the medicaid managed
care organization, except that the results may
not be made available in a manner that discloses
the identity of any individual patient.
‘‘(2) DEEMED COMPLIANCE.—
‘‘(A) MEDICARE ORGANIZATIONS.—The re-
quirements of paragraph (1) shall not apply
with respect to a medicaid managed care organi-
zation if the organization is an eligible organiza-
tion with a contract in effect under section 1876
or under part C of title XVIII.
‘‘(B) PRIVATE ACCREDITATION.—
‘‘(i) IN
GENERAL.—The requirements
of paragraph (1) shall not apply with re-
spect to a medicaid managed care organiza-
tion if—
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HR 2015 EAS
‘‘(I) the organization is accredited
by an organization meeting the re-
quirements described in subparagraph
(C)), and
‘‘(II) the standards and process
under which the organization is ac-
credited meet such requirements as are
established under clause (ii), without
regard to whether or not the time re-
quirement of such clause is satisfied.
‘‘(ii) STANDARDS AND PROCESS.—Not
later than 180 days after the date of the en-
actment of this section, the Secretary shall
specify requirements for the standards and
process under which a medicaid managed
care organization is accredited by an orga-
nization meeting the requirements of sub-
paragraph (B).
‘‘(C) ACCREDITING ORGANIZATION.—An ac-
crediting organization meets the requirements of
this subparagraph if the organization—
‘‘(i) is a private, nonprofit organiza-
tion,
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HR 2015 EAS
‘‘(ii) exists for the primary purpose of
accrediting managed care organizations or
health care providers, and
‘‘(iii) is independent of health care
providers or associations of health care pro-
viders.
‘‘(3) REVIEW OF PRIMARY CARE CASE MANAGER
CONTRACT.—Each primary care case manager shall
be subject to an annual external independent review
of the quality and timeliness of, and access to, the
items and services specified in the contract entered
into between the State and the primary care case
manager under section 1941(a)(1)(B).
‘‘(4) USE OF VALIDATION SURVEYS.—The Sec-
retary shall conduct surveys each year to validate ex-
ternal reviews of the number of managed care entities
in the year. In conducting such surveys the Secretary
shall use the same protocols as were used in preparing
the external reviews. If an external review finds that
an individual managed care entity meets applicable
requirements, but the Secretary determines that the
entity does not meet such requirements, the Sec-
retary’s determination as to the entity’s noncompli-
ance with such requirements is binding and super-
sedes that of the previous survey.
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‘‘(b) FEDERAL MONITORING RESPONSIBILITIES.—The
Secretary shall review the external independent reviews con-
ducted pursuant to subsection (a) and shall monitor the ef-
fectiveness of the State’s monitoring of managed care enti-
ties and any followup activities required under this part.
If the Secretary determines that a State’s monitoring and
followup activities are not adequate to ensure that the re-
quirements of such section are met, the Secretary shall un-
dertake appropriate followup activities to ensure that the
State improves its monitoring and followup activities.
‘‘(c) PROVIDING INFORMATION ON SERVICES.—
‘‘(1) REQUIREMENTS
FOR
MEDICAID
MANAGED
CARE ORGANIZATIONS.—Each medicaid managed care
organization shall provide to the State complete and
timely information concerning the following:
‘‘(A) The services that the organization pro-
vides to (or arranges to be provided to) individ-
uals eligible for medical assistance under the
State plan under this title.
‘‘(B) The identity, locations, qualifications,
and availability of participating health care
providers.
‘‘(C) The rights and responsibilities of en-
rollees.
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HR 2015 EAS
‘‘(D) The services provided by the organiza-
tion which are subject to prior authorization by
the organization as a condition of coverage (in
accordance with subsection (d)).
‘‘(E) The procedures available to an enrollee
and a health care provider to appeal the failure
of the organization to cover a service.
‘‘(F) The performance of the organization in
serving individuals eligible for medical assist-
ance under the State plan under this title.
Such information shall be provided in a form consist-
ent with the reporting of similar information by eligi-
ble organizations under section 1876 or under part C
of title XVIII.
‘‘(2) REQUIREMENTS FOR PRIMARY CARE CASE
MANAGERS.—Each 
primary 
care 
case 
manager
shall—
‘‘(A) provide to the State (at least at such
frequency as the Secretary may require), com-
plete and timely information concerning the
services that the primary care case manager pro-
vides to (or arranges to be provided to) individ-
uals eligible for medical assistance under the
State plan under this title,
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‘‘(B) make available to enrollees and poten-
tial enrollees information concerning services
available to the enrollee for which prior author-
ization by the primary care case manager is re-
quired,
‘‘(C) provide enrollees and potential enroll-
ees information regarding all items and services
that are available to enrollees under the contract
between the State and the primary care case
manager that are covered either directly or
through a method of referral and prior author-
ization, and
‘‘(D) provide assurances that such entities
and their professional personnel are licensed as
required by State law and qualified to provide
case management services, through methods such
as ongoing monitoring of compliance with appli-
cable requirements and providing information
and technical assistance.
‘‘(3) REQUIREMENTS FOR BOTH MEDICAID MAN-
AGED CARE ORGANIZATIONS AND PRIMARY CARE CASE
MANAGERS.—Each managed care entity shall provide
the State with aggregate encounter data for all items
and services, including early and periodic screening,
diagnostic, and treatment services under section
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1905(r) furnished to individuals under 21 years of
age. Any such data provided may be audited by the
State.
‘‘(d) CONDITIONS FOR PRIOR AUTHORIZATION.—Sub-
ject to section 1943, a managed care entity may require
the approval of medical assistance for nonemergency serv-
ices before the assistance is furnished to an enrollee only
if the system providing for such approval provides that such
decisions are made in a timely manner, depending upon
the urgency of the situation.
‘‘(e) PATIENT ENCOUNTER DATA.—Each medicaid
managed care organization shall maintain sufficient pa-
tient encounter data to identify the health care provider
who delivers services to patients and to otherwise enable the
State plan to meet the requirements of section 1902(a)(27)
and shall submit such data to the State or the Secretary
upon request. The medicaid managed care organization
shall incorporate such information in the maintenance of
patient encounter data with respect to such health care pro-
vider.
‘‘(f) INCENTIVES FOR HIGH QUALITY MANAGED CARE
ENTITIES.—The Secretary and the State may establish a
program to reward, through public recognition, incentive
payments, or enrollment of additional individuals (or com-
binations of such rewards), managed care entities that pro-
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vide the highest quality care to individuals eligible for med-
ical assistance under the State plan under this title who
are enrolled with such entities. For purposes of section
1903(a)(7), proper expenses incurred by a State in carrying
out such a program shall be considered to be expenses nec-
essary for the proper and efficient administration of the
State plan under this title.
‘‘(g) QUALITY ASSURANCE STANDARDS.—Any contract
between a State and a managed care entity shall provide—
‘‘(1) that the State agency will develop and im-
plement a State specific quality assessment and im-
provement strategy, consistent with standards that the
Secretary, in consultation with the States, shall estab-
lish and monitor (but that shall not preempt any
State standards that are more stringent than the
standards established under this paragraph), and that
includes—
‘‘(A) standards for access to care so that
covered services are available within reasonable
timeframes and in a manner that ensures con-
tinuity of care and adequate primary care and
specialized services capacity; and
‘‘(B) procedures for monitoring and evalu-
ating the quality and appropriateness of care
and services to beneficiaries that reflect the full
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spectrum of populations enrolled in the plan and
that include—
‘‘(i) requirements for provision of qual-
ity assurance data to the State using the
data and information set that the Sec-
retary, in consultation with the States, shall
specify with respect to entities contracting
under section 1876 or under part C of title
XVIII or alternative data requirements ap-
proved by the Secretary;
‘‘(ii) if necessary, an annual examina-
tion of the scope and content of the quality
improvement strategy; and
‘‘(iii) other aspects of care and service
directly related to the improvement of qual-
ity of care (including grievance procedures
and marketing and information standards),
‘‘(2) that entities entering into such agreements
under which payment is made on a prepaid capitated
or other risk basis shall be required—
‘‘(A) to submit to the State agency informa-
tion that demonstrates significant improvement
in the care delivered to members;
‘‘(B) to maintain an internal quality assur-
ance program consistent with paragraph (1),
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and meeting standards that the Secretary, in
consultation with the States, shall establish in
regulations; and
‘‘(C) to provide effective procedures for hear-
ing and resolving grievances between the entity
and members enrolled with the entity under this
section, and
‘‘(3) that provision is made, consistent with
State law or with regulations under State law, with
respect to the solvency of those entities, financial re-
porting by those entities, and avoidance of waste,
fraud, and abuse.
‘‘(h) ANNUAL REPORT
ON NON-HEALTH EXPENDI-
TURES.—Each medicaid managed care organization shall
annually provide to enrollees a statement disclosing the pro-
portion of the premiums and other revenues received by the
organization that are expended for non-health care items
and services.
‘‘SEC. 1946. PROTECTIONS FOR PROVIDERS.
‘‘(a) TIMELINESS OF PAYMENT.—A medicaid managed
care organization shall make payment to health care pro-
viders for items and services which are subject to the con-
tract under section 1941(a)(1)(B) and which are furnished
to individuals eligible for medical assistance under the
State plan under this title who are enrolled with the entity