Teacher:In this task, you are given text for US Congressional and California state bills, your task is to generate a summary for this bill.
Teacher: Now, understand the problem? Solve this instance: SECTION 1. SHORT TITLE.

This Act may be cited as the ''Medicare Patient Choice Act of
1995''.

SEC. 2. FINDINGS.

Congress finds the following:
(1) There should be no unreasonable barriers or impediments
to the ability of individuals enrolled in health care plans to
obtain appropriate specialized medical services.
(2) The patient's first point of contact in a health care
plan must be encouraged to make all appropriate medical
referrals and should not be constrained financially from making
such referrals.
(3) Some health care plans may impede timely access to
specialty care.
(4) At any time, patients must be able to access out-of-
network items, treatment, and services at an additional cost to
the patient which is not so prohibitive that they are deterred
from seeing the health care provider of their own choice.
(5) Specialty care must be available for the full duration
of the patient's medical needs and not limited by time or
number of visits.
(6) Direct access to specialty care is essential for
patients in emergency and nonemergency situations and for
patients with chronic and temporary conditions.

SEC. 3. PROTECTION FOR MEDICARE HMO ENROLLEES.

(a) In General.--Section 1876 of the Social Security Act (42 U.S.C.
1395mm) is amended--
(1) in subsection (c)(1), by striking ''subsection (e)''
and inserting ''subsections (e) and (k)'', and
(2) by adding at the end the following new subsection:
''(k) Beneficiary Protection.--
''(1) Minimum loss ratio.--
''(A) In general.--Each eligible organization shall
have a loss-ratio that is not less than 85 percent for
each contract year.
''(B) Loss ratio defined.--In subparagraph (A), the
term 'loss-ratio' means, with respect to an
organization for a contract year, the ratio of (i) the
anticipated aggregate benefits provided under this
section to enrollees for the year, to (ii) the
aggregate amount of the premiums collected (including
payments to the organization under subsection (a) for
the year, as estimated on the basis of incurred claims
experience and earned premium for the year.
''(2) Assuring adequate in-network access.--
''(A) Timely access.--An eligible organization that
restricts the providers from whom benefits may be
obtained must guarantee to enrollees under this section
timely access to primary and specialty health care
providers who are appropriate to the enrollee's
condition.
''(B) Access to specialized care.--Enrollees must
have access to specialized treatment when the treating
provider deems necessary. This access may be satisfied
through contractual arrangements with specialized
providers outside of the network.
''(C) Continuity of care.--An eligible
organization's use of case management may not create an
undue burden for enrollees under this section. An
organization must ensure direct access to specialists
for ongoing care as so determined by the case manager
in consultation with the specialty care provider. This
continuity of care may be satisfied for enrollees with
chronic conditions through the use of a specialist
serving as case manager.
''(3) Assuring out-of-network access.--
''(A) In general.--An eligible organization that
contracts with a specific network of providers must
offer its enrollees or their treating provider with the
patient's authorization under this section, the ability
at any time, to seek items, services, and treatment
from out-of-network providers for all covered benefits.
''(B) Reimbursement for out-of-network services.--
An eligible organization under this section shall
provide for reimbursement for the enrollee, consistent
with the cost-sharing schedule established under
subparagraph (C), with respect to out-of-network
services which are described in subparagraph (A), so
long as the services were medically appropriate, and
were covered benefits in-network.
''(C) Establishment of cost-sharing schedule.--In
consultation with the National Association of Insurance
Commissioners, the Secretary shall establish (by not
later than one year after enactment of this Act) a
cost-sharing schedule which applies to payment required
under subparagraph (B) for out-of-network services.
''(4) Appropriate range of services.--A health plan shall
not deny any health care professionals, based solely on the
license or certification as applicable under State law, the
ability to participate in providing covered health care
services, or be reimbursed or indemnified or by a network plan
for providing such services. Organizations must ensure a
sufficient number, mix, and distribution of health care
professionals within a network plan to ensure enrollees access
to appropriate medical services.
''(5) Grievance and appeals processes.--
''(A) Grievance process.--The organization must
provide meaningful procedures for hearing and resolving
grievances between the organization (including any
entity or individual through which the organization
provides health care services) and members enrolled
with the organization under this section.
''(B) Board of appeals.--
''(i) In general.--Each eligible
organization shall establish a board of appeals
to hear and make determinations on complaints
by enrollees concerning denials of coverage or
payment for services (whether in-network or
out-of-network) and the medical necessity and
appropriateness of covered items and services.
''(ii) Composition.--A board of appeals of
an eligible organization shall consist of--
''(I) representatives of the
organization, including physicians,
nonphysicians, administrators, and
enrollees;
''(II) consumers who are not
enrollees and those who have
disenrolled; and
''(III) providers with expertise in
the field of medicine which
necessitates treatment.
''(iii) Deadline for decision.--A board of
appeals shall hear and resolve complaints
within 30 days after the date the complaint is
filed with the board.
''(C) Appeal to secretary.--A member enrolled in an
eligible organization under this section who is
dissatisfied with a determination of a board of appeals
of the organization under subparagraph (B) is entitled,
if the amount in controversy is $100 or more, to a
hearing before the Secretary to the same extent as is
provided in section 205(b), and in any such hearing the
Secretary shall make the eligible organization a party.
If the amount in controversy is $1,000 or more, the
individual or eligible organization shall, upon
notifying the other party, be entitled to judicial
review of the Secretary's final decision as provided in
section 205(g), and both the individual and the
eligible organization shall be entitled to be parties
to that judicial review. In applying sections 205(b)
and 205(g) as provided in this subparagraph, and in
applying section 205(l) thereto, any reference therein
to the Commissioner of Social Security or the Social
Security Administration shall be considered a reference
to the Secretary or the Department of Health and Human
Services, respectively.
''(6) Notice of enrollee rights and consumer report card.--
''(A) In general.--Each eligible organization shall
provide each enrollee, at the time of enrollment and
not less frequently than annually thereafter, an
explanation of the enrollee's rights under this section
and a copy of the most recent consumer report card for
the organization (as described in subparagraph (C)).
''(B) Rights described.--The explanation 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 services
covered under parts A and B; and
''(vi) appeal rights of enrollees.
''(C) Consumer report card.--For purposes of
subparagraph (A), the term 'consumer report card'
means, with respect to an eligible organization for a
year, a report issued by the organization which
contains indicators of the quality of the services
under this section provided by the organization during
the year. Information must be provided in a manner that
permits consumers to compare organizations with respect
to the following:
''(i) For each plan, on--
''(I) the premium for the plan,
''(II) identity, location,
qualifications, 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,
''(VI) the plan's loss ratio, and
''(VII) rights and responsibilities
of enrollees.
''(ii) In addition, for each managed care
plan, on--
''(I) restrictions on payment for
services provided outside the plan's
provider network,
''(II) the process by which
services 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.
''(7) 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 subparagraph (B)) unless the
following requirements are met:
''(i) No specific payment is made directly
or indirectly under the plan to a provider or
provider group as an inducement to reduce or
limit medically necessary services provided
with respect to a specific individual enrolled
with the organization.
''(ii) If the plan places a provider or
provider group at substantial financial risk
(as determined by the Secretary) for services
not provided by the provider or provider group,
the organization--
''(I) provides stop-loss protection
for the provider or group that is
adequate 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 organization who receive
services from the provider or the group, and
''(II) conducts periodic surveys of
both individuals enrolled and
individuals previously enrolled with
the organization to determine the
degree of access of such individuals to
services provided by the organization
and satisfaction with the quality of
such services.
''(iii) The organization provides the
Secretary with descriptive information
regarding 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 defined.--In this
paragraph, the term 'provider incentive plan' means any
compensation arrangement between an eligible
organization and a provider or provider group that may
directly or indirectly have the effect of reducing or
limiting services provided with respect to individuals
enrolled with the organization.
''(8) Additional definitions.--
''(A) In-network.--The term 'in-network' means
services provided by health care providers who have
entered into a contract or agreement with the
organization under which such providers are obligated
to provide items, treatment, and services under this
section to individuals enrolled with the organization
under this section.
''(B) Network.--The term 'network' means, with
respect to an eligible organization, the health care
providers who have entered into a contract or agreement
with the organization under which such providers are
obligated to provide items, treatment, and services
under this section to individuals enrolled with the
organization under this section.
''(C) Out-of-network.--The term 'out-of-network'
means services provided by health care providers who
have not entered into a contract agreement with the
organization under which such providers are obligated
to provide items, treatment, and services under this
section to individuals enrolled with the organization
under this section.''.
(b) Conforming Amendments.--Section 1876 of such Act is further
amended--
(1) by striking subparagraph (E) of subsection (c)(3);
(2) by striking paragraphs (4) and (5) of subsection (c);
and
(3) by striking paragraph (8) of subsection (i).
(c) Effective Date.--The amendments made by this section shall
apply to contract years beginning at least 60 days after the date the
Secretary establishes the cost-sharing schedule for out-of-network
services under section 1876(k)(2)(C) of the Social Security Act (as
added by subsection (a)(2)).

SEC. 4. APPLICATION OF PROTECTIONS TO MEDICARE SELECT POLICIES.

(a) In General.--Section 1882(t)(1) of the Social Security Act (42
U.S.C. 1395ss(t)(1)) is amended--
(1) by striking ''and'' at the end of subparagraph (E);
(2) by striking the period at the end of subparagraph (F)
and inserting a semicolon; and
(3) by adding at the end the following new subparagraph:
''(G) notwithstanding any other provision of this
section to the contrary, if the issuer of the policy--
''(i) meets the requirements of section
1876(k) with respect to individuals enrolled
under the policy in the same manner such
requirements apply with respect to an eligible
organization under such section with respect to
individuals enrolled with the organization
under such section, and
''(ii) discloses (in a form and manner
specified by the Secretary) the loss ratio
described in subsection (r)(1) most recently
calculated for purposes of such subsection.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to policies issued or renewed on or after the effective date
described in section 3(c).
Student:
Medicare Patient Choice Act of 1995 - Amends title XVIII (Medicare) of the Social Security Act to require health maintenance organizations and competitive medical plans, among other things, to: (1) have a minimum 85 percent loss-ratio of benefits-to-premiums; (2) assure Medicare enrollees timely access to in-network primary and specialty health care providers and out-of-network providers as well; (3) establish a cost-sharing schedule for out-of-network services; (4) establish a grievance process with board of appeals hearings within 30 days of the filing of a complaint; and (5) provide each enrollee with an explanation of the enrollee's rights and a copy of the most recent consumer report card for the organization. Prohibits provider incentive plans that fail to meet specified criteria.
Applies the same requirements to Medicare select policies.