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[Laws in effect as of January 23, 2000]
[Document affected by Public Law 106-554 Section 1(a)(6)]
[Document affected by Public Law 106-554 Section 1(a)(6)[521(b)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[611(b)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[621(a)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[611(c)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[621(b)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[621(c)]]
[CITE: 42USC1395w-22]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
                     Part C--Medicare+Choice Program
 
Sec. 1395w-22. Benefits and beneficiary protections


(a) Basic benefits

                           (1) In general

        Except as provided in section 1395w-28(b)(3) of this title for 
    MSA plans, each Medicare+
    Choice plan shall provide to members enrolled under this part, 
    through providers and other persons that meet the applicable 
    requirements of this subchapter and part A of subchapter XI of this 
    chapter--
            (A) those items and services (other than hospice care) for 
        which benefits are available under parts A and B of this 
        subchapter to individuals residing in the area served by the 
        plan, and
            (B) additional benefits required under section 1395w-
        24(f)(1)(A) of this title.

                   (2) Satisfaction of requirement

        (A) In general

            A Medicare+Choice plan (other than an MSA plan) offered by a 
        Medicare+Choice organization satisfies paragraph (1)(A), with 
        respect to benefits for items and services furnished other than 
        through a provider or other person that has a contract with the 
        organization offering the plan, if the plan provides payment in 
        an amount so that--
                (i) the sum of such payment amount and any cost sharing 
            provided for under the plan, is equal to at least
                (ii) the total dollar amount of payment for such items 
            and services as would otherwise be authorized under parts A 
            and B of this subchapter (including any balance billing 
            permitted under such parts).

        (B) Reference to related provisions

            For provision relating to--
                (i) limitations on balance billing against 
            Medicare+Choice organizations for non-contract providers, 
            see subsection (k) of this section and section 
            1395cc(a)(1)(O) of this title, and
                (ii) limiting actuarial value of enrollee liability for 
            covered benefits, see section 1395w-24(e) of this title.

                      (3) Supplemental benefits

        (A) Benefits included subject to Secretary's approval

            Each Medicare+Choice organization may provide to individuals 
        enrolled under this part, other than under an MSA plan (without 
        affording those individuals an option to decline the coverage), 
        supplemental health care benefits that the Secretary may 
        approve. The Secretary shall approve any such supplemental 
        benefits unless the Secretary determines that including such 
        supplemental benefits would substantially discourage enrollment 
        by Medicare+Choice eligible individuals with the organization.

        (B) At enrollees' option

            (i) In general

                Subject to clause (ii), a Medicare+Choice organization 
            may provide to individuals enrolled under this part 
            supplemental health care benefits that the individuals may 
            elect, at their option, to have covered.
            (ii) Special rule for MSA plans

                A Medicare+Choice organization may not provide, under an 
            MSA plan, supplemental health care benefits that cover the 
            deductible described in section 1395w-28(b)(2)(B) of this 
            title. In applying the previous sentence, health benefits 
            described in section 1395ss(u)(2)(B) of this title shall not 
            be treated as covering such deductible.

        (C) Application to Medicare+Choice private fee-for-service plans

            Nothing in this paragraph shall be construed as preventing a 
        Medicare+Choice private fee-for-service plan from offering 
        supplemental benefits that include payment for some or all of 
        the balance billing amounts permitted consistent with subsection 
        (k) of this section and coverage of additional services that the 
        plan finds to be medically necessary.

                 (4) Organization as secondary payer

        Notwithstanding any other provision of law, a Medicare+Choice 
    organization may (in the case of the provision of items and services 
    to an individual under a Medicare+Choice plan under circumstances in 
    which payment under this subchapter is made secondary pursuant to 
    section 1395y(b)(2) of this title) charge or authorize the provider 
    of such services to charge, in accordance with the charges allowed 
    under a law, plan, or policy described in such section--
            (A) the insurance carrier, employer, or other entity which 
        under such law, plan, or policy is to pay for the provision of 
        such services, or
            (B) such individual to the extent that the individual has 
        been paid under such law, plan, or policy for such services.

                (5) National coverage determinations

        If there is a national coverage determination made in the period 
    beginning on the date of an announcement under section 1395w-23(b) 
    of this title and ending on the date of the next announcement under 
    such section and the Secretary projects that the determination will 
    result in a significant change in the costs to a Medicare+Choice 
    organization of providing the benefits that are the subject of such 
    national coverage determination and that such change in costs was 
    not incorporated in the determination of the annual Medicare+Choice 
    capitation rate under section 1395w-23 of this title included in the 
    announcement made at the beginning of such period, then, unless 
    otherwise required by law--
            (A) such determination shall not apply to contracts under 
        this part until the first contract year that begins after the 
        end of such period, and
            (B) if such coverage determination provides for coverage of 
        additional benefits or coverage under additional circumstances, 
        section 1395w-21(i)(1) of this title shall not apply to payment 
        for such additional benefits or benefits provided under such 
        additional circumstances until the first contract year that 
        begins after the end of such period.

(b) Antidiscrimination

                          (1) Beneficiaries

        (A) In general

            A Medicare+Choice organization may not deny, limit, or 
        condition the coverage or provision of benefits under this part, 
        for individuals permitted to be enrolled with the organization 
        under this part, based on any health status-related factor 
        described in section 300gg-1(a)(1) of this title.

        (B) Construction

            Subparagraph (A) shall not be construed as requiring a 
        Medicare+Choice organization to enroll individuals who are 
        determined to have end-stage renal disease, except as provided 
        under section 1395w-21(a)(3)(B) of this title.

                            (2) Providers

        A Medicare+Choice organization shall not discriminate with 
    respect to participation, reimbursement, or indemnification as to 
    any provider who is acting within the scope of the provider's 
    license or certification under applicable State law, solely on the 
    basis of such license or certification. This paragraph shall not be 
    construed to prohibit a plan from including providers only to the 
    extent necessary to meet the needs of the plan's enrollees or from 
    establishing any measure designed to maintain quality and control 
    costs consistent with the responsibilities of the plan.

(c) Disclosure requirements

             (1) Detailed description of plan provisions

        A Medicare+Choice organization shall disclose, in clear, 
    accurate, and standardized form to each enrollee with a 
    Medicare+Choice plan offered by the organization under this part at 
    the time of enrollment and at least annually thereafter, the 
    following information regarding such plan:

        (A) Service area

            The plan's service area.

        (B) Benefits

            Benefits offered under the plan, including information 
        described in section 1395w-21(d)(3)(A) of this title and 
        exclusions from coverage and, if it is an MSA plan, a comparison 
        of benefits under such a plan with benefits under other 
        Medicare+Choice plans.

        (C) Access

            The number, mix, and distribution of plan providers, out-of-
        network coverage (if any) provided by the plan, and any point-
        of-service option (including the supplemental premium for such 
        option).

        (D) Out-of-area coverage

            Out-of-area coverage provided by the plan.

        (E) Emergency coverage

            Coverage of emergency services, including--
                (i) the appropriate use of emergency services, including 
            use of the 911 telephone system or its local equivalent in 
            emergency situations and an explanation of what constitutes 
            an emergency situation;
                (ii) the process and procedures of the plan for 
            obtaining emergency services; and
                (iii) the locations of (I) emergency departments, and 
            (II) other settings, in which plan physicians and hospitals 
            provide emergency services and post-stabilization care.

        (F) Supplemental benefits

            Supplemental benefits available from the organization 
        offering the plan, including--
                (i) whether the supplemental benefits are optional,
                (ii) the supplemental benefits covered, and
                (iii) the Medicare+Choice monthly supplemental 
            beneficiary premium for the supplemental benefits.

        (G) Prior authorization rules

            Rules regarding prior authorization or other review 
        requirements that could result in nonpayment.

        (H) Plan grievance and appeals procedures

            All plan appeal or grievance rights and procedures.

        (I) Quality assurance program

            A description of the organization's quality assurance 
        program under subsection (e) of this section.

                     (2) Disclosure upon request

        Upon request of a Medicare+Choice eligible individual, a 
    Medicare+Choice organization must provide the following information 
    to such individual:
            (A) The general coverage information and general comparative 
        plan information made available under clauses (i) and (ii) of 
        section 1395w-21(d)(2)(A) of this title.
            (B) Information on procedures used by the organization to 
        control utilization of services and expenditures.
            (C) Information on the number of grievances, 
        redeterminations, and appeals and on the disposition in the 
        aggregate of such matters.
            (D) An overall summary description as to the method of 
        compensation of participating physicians.

(d) Access to services

                           (1) In general

        A Medicare+Choice organization offering a Medicare+Choice plan 
    may select the providers from whom the benefits under the plan are 
    provided so long as--
            (A) the organization makes such benefits available and 
        accessible to each individual electing the plan within the plan 
        service area with reasonable promptness and in a manner which 
        assures continuity in the provision of benefits;
            (B) when medically necessary the organization makes such 
        benefits available and accessible 24 hours a day and 7 days a 
        week;
            (C) the plan provides for reimbursement with respect to 
        services which are covered under subparagraphs (A) and (B) and 
        which are provided to such an individual other than through the 
        organization, if--
                (i) the services were not emergency services (as defined 
            in paragraph (3)), but (I) the services were medically 
            necessary and immediately required because of an unforeseen 
            illness, injury, or condition, and (II) it was not 
            reasonable given the circumstances to obtain the services 
            through the organization,
                (ii) the services were renal dialysis services and were 
            provided other than through the organization because the 
            individual was temporarily out of the plan's service area, 
            or
                (iii) the services are maintenance care or post-
            stabilization care covered under the guidelines established 
            under paragraph (2);

            (D) the organization provides access to appropriate 
        providers, including credentialed specialists, for medically 
        necessary treatment and services; and
            (E) coverage is provided for emergency services (as defined 
        in paragraph (3)) without regard to prior authorization or the 
        emergency care provider's contractual relationship with the 
        organization.

    (2) Guidelines respecting coordination of post-stabilization 
                                    care

        A Medicare+Choice plan shall comply with such guidelines as the 
    Secretary may prescribe relating to promoting efficient and timely 
    coordination of appropriate maintenance and post-stabilization care 
    of an enrollee after the enrollee has been determined to be stable 
    under section 1395dd of this title.

                 (3) ``Emergency services'' defined

        In this subsection--

        (A) In general

            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 subchapter, and
                (ii) are needed to evaluate or stabilize an emergency 
            medical condition (as defined in subparagraph (B)).

        (B) Emergency medical condition based on prudent layperson

            The term ``emergency medical condition'' means a medical 
        condition manifesting itself by acute symptoms of sufficient 
        severity (including severe pain) such that a prudent layperson, 
        who possesses an average knowledge 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.

            (4) Assuring access to services in Medicare+
                    Choice private fee-for-service plans

        In addition to any other requirements under this part, in the 
    case of a Medicare+Choice private fee-for-service plan, the 
    organization offering the plan must demonstrate to the Secretary 
    that the organization has sufficient number and range of health care 
    professionals and providers willing to provide services under the 
    terms of the plan. The Secretary shall find that an organization has 
    met such requirement with respect to any category of health care 
    professional or provider if, with respect to that category of 
    provider--
            (A) the plan has established payment rates for covered 
        services furnished by that category of provider that are not 
        less than the payment rates provided for under part A of this 
        subchapter, part B of this subchapter, or both, for such 
        services, or
            (B) the plan has contracts or agreements with a sufficient 
        number and range of providers within such category to provide 
        covered services under the terms of the plan,

    or a combination of both. The previous sentence shall not be 
    construed as restricting the persons from whom enrollees under such 
    a plan may obtain covered benefits.

(e) Quality assurance program

                           (1) In general

        Each Medicare+Choice organization must have arrangements, 
    consistent with any regulation, for an ongoing quality assurance 
    program for health care services it provides to individuals enrolled 
    with Medicare+Choice plans of the organization.

                       (2) Elements of program

        (A) In general

            The quality assurance program of an organization with 
        respect to a Medicare+Choice plan (other than a Medicare+Choice 
        private fee-for-service plan, a non-network MSA plan, or a 
        preferred provider organization plan) it offers shall--
                (i) stress health outcomes and provide for the 
            collection, analysis, and reporting of data (in accordance 
            with a quality measurement system that the Secretary 
            recognizes) that will permit measurement of outcomes and 
            other indices of the quality of Medicare+Choice plans and 
            organizations;
                (ii) monitor and evaluate high volume and high risk 
            services and the care of acute and chronic conditions;
                (iii) evaluate the continuity and coordination of care 
            that enrollees receive;
                (iv) be evaluated on an ongoing basis as to its 
            effectiveness;
                (v) include measures of consumer satisfaction;
                (vi) provide the Secretary with such access to 
            information collected as may be appropriate to monitor and 
            ensure the quality of care provided under this part;
                (vii) provide review by physicians and other health care 
            professionals of the process followed in the provision of 
            such health care services;
                (viii) provide for the establishment of written 
            protocols for utilization review, based on current standards 
            of medical practice;
                (ix) have mechanisms to detect both underutilization and 
            overutilization of services;
                (x) after identifying areas for improvement, establish 
            or alter practice parameters;
                (xi) take action to improve quality and assesses the 
            effectiveness of such action through systematic followup; 
            and
                (xii) make available information on quality and outcomes 
            measures to facilitate beneficiary comparison and choice of 
            health coverage options (in such form and on such quality 
            and outcomes measures as the Secretary determines to be 
            appropriate).

        (B) Elements of program for organizations offering 
                Medicare+Choice private fee-for-service plans, non-
                network MSA plans, and preferred provider organization 
                plans

            The quality assurance program of an organization with 
        respect to a Medicare+Choice private fee-for-service plan, a 
        non-network MSA plan, or a preferred provider organization plan 
        it offers shall--
                (i) meet the requirements of clauses (i) through (vi) of 
            subparagraph (A);
                (ii) insofar as it provides for the establishment of 
            written protocols for utilization review, base such 
            protocols on current standards of medical practice; and
                (iii) have mechanisms to evaluate utilization of 
            services and inform providers and enrollees of the results 
            of such evaluation.

        (C) ``Non-network MSA plan'' defined

            In this subsection, the term ``non-network MSA plan'' means 
        an MSA plan offered by a Medicare+Choice organization that does 
        not provide benefits required to be provided by this part, in 
        whole or in part, through a defined set of providers under 
        contract, or under another arrangement, with the organization.

        (D) Definition of preferred provider organization plan

            In this paragraph, the term ``preferred provider 
        organization plan'' means a Medicare+Choice plan that--
                (i) has a network of providers that have agreed to a 
            contractually specified reimbursement for covered benefits 
            with the organization offering the plan;
                (ii) provides for reimbursement for all covered benefits 
            regardless of whether such benefits are provided within such 
            network of providers; and
                (iii) is offered by an organization that is not licensed 
            or organized under State law as a health maintenance 
            organization.

                         (3) External review

        (A) In general

            Each Medicare+Choice organization shall, for each 
        Medicare+Choice plan it operates, have an agreement with an 
        independent quality review and improvement organization approved 
        by the Secretary to perform functions of the type described in 
        sections 1320c-3(a)(4)(B) and 1320c-3(a)(14) of this title with 
        respect to services furnished by Medicare+Choice plans for which 
        payment is made under this subchapter. The previous sentence 
        shall not apply to a Medicare+
        Choice private fee-for-service plan or a non-network MSA plan 
        that does not employ utilization review.

        (B) Nonduplication of accreditation

            Except in the case of the review of quality complaints, and 
        consistent with subparagraph (C), the Secretary shall ensure 
        that the external review activities conducted under subparagraph 
        (A) are not duplicative of review activities conducted as part 
        of the accreditation process.

        (C) Waiver authority

            The Secretary may waive the requirement described in 
        subparagraph (A) in the case of an organization if the Secretary 
        determines that the organization has consistently maintained an 
        excellent record of quality assurance and compliance with other 
        requirements under this part.

                   (4) Treatment of accreditation

        (A) In general

            The Secretary shall provide that a Medicare+Choice 
        organization is deemed to meet all the requirements described in 
        any specific clause of subparagraph (B) if the organization is 
        accredited (and periodically reaccredited) by a private 
        accrediting organization under a process that the Secretary has 
        determined assures that the accrediting organization applies and 
        enforces standards that meet or exceed the standards established 
        under section 1395w-26 of this title to carry out the 
        requirements in such clause.

        (B) Requirements described

            The provisions described in this subparagraph are the 
        following:
                (i) Paragraphs (1) and (2) of this subsection (relating 
            to quality assurance programs).
                (ii) Subsection (b) of this section (relating to 
            antidiscrimination).
                (iii) Subsection (d) of this section (relating to access 
            to services).
                (iv) Subsection (h) of this section (relating to 
            confidentiality and accuracy of enrollee records).
                (v) Subsection (i) of this section (relating to 
            information on advance directives).
                (vi) Subsection (j) of this section (relating to 
            provider participation rules).

        (C) Timely action on applications

            The Secretary shall determine, within 210 days after the 
        date the Secretary receives an application by a private 
        accrediting organization and using the criteria specified in 
        section 1395bb(b)(2) of this title, whether the process of the 
        private accrediting organization meets the requirements with 
        respect to any specific clause in subparagraph (B) with respect 
        to which the application is made. The Secretary may not deny 
        such an application on the basis that it seeks to meet the 
        requirements with respect to only one, or more than one, such 
        specific clause.

        (D) Construction

            Nothing in this paragraph shall be construed as limiting the 
        authority of the Secretary under section 1395w-27 of this title, 
        including the authority to terminate contracts with 
        Medicare+Choice organizations under subsection (c)(2) of such 
        section.

(f) Grievance mechanism

    Each Medicare+Choice 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 enrollees with Medicare+Choice plans of the 
organization under this part.

(g) Coverage determinations, reconsiderations, and appeals

                 (1) Determinations by organization

        (A) In general

            A Medicare+Choice organization shall have a procedure for 
        making determinations regarding whether an individual enrolled 
        with the plan of the organization under this part is entitled to 
        receive a health service under this section and the amount (if 
        any) that the individual is required to pay with respect to such 
        service. Subject to paragraph (3), such procedures shall provide 
        for such determination to be made on a timely basis.

        (B) Explanation of determination

            Such a determination that denies coverage, in whole or in 
        part, shall be in writing and shall include a statement in 
        understandable language of the reasons for the denial and a 
        description of the reconsideration and appeals processes.

                        (2) Reconsiderations

        (A) In general

            The organization shall provide for reconsideration of a 
        determination described in paragraph (1)(B) upon request by the 
        enrollee involved. The reconsideration shall be within a time 
        period specified by the Secretary, but shall be made, subject to 
        paragraph (3), not later than 60 days after the date of the 
        receipt of the request for reconsideration.

        (B) Physician decision on certain reconsiderations

            A reconsideration relating to a determination to deny 
        coverage based on a lack of medical necessity shall be made only 
        by a physician with appropriate expertise in the field of 
        medicine which necessitates treatment who is other than a 
        physician involved in the initial determination.

          (3) Expedited determinations and reconsiderations

        (A) Receipt of requests

            (i) Enrollee requests

                An enrollee in a Medicare+Choice plan may request, 
            either in writing or orally, an expedited determination 
            under paragraph (1) or an expedited reconsideration under 
            paragraph (2) by the Medicare+
            Choice organization.
            (ii) Physician requests

                A physician, regardless whether the physician is 
            affiliated with the organization or not, may request, either 
            in writing or orally, such an expedited determination or 
            reconsideration.

        (B) Organization procedures

            (i) In general

                The Medicare+Choice organization shall maintain 
            procedures for expediting organization determinations and 
            reconsiderations when, upon request of an enrollee, the 
            organization determines that the application of the normal 
            time frame for making a determination (or a reconsideration 
            involving a determination) could seriously jeopardize the 
            life or health of the enrollee or the enrollee's ability to 
            regain maximum function.
            (ii) Expedition required for physician requests

                In the case of a request for an expedited determination 
            or reconsideration made under subparagraph (A)(ii), the 
            organization shall expedite the determination or 
            reconsideration if the request indicates that the 
            application of the normal time frame for making a 
            determination (or a reconsideration involving a 
            determination) could seriously jeopardize the life or health 
            of the enrollee or the enrollee's ability to regain maximum 
            function.
            (iii) Timely response

                In cases described in clauses (i) and (ii), the 
            organization shall notify the enrollee (and the physician 
            involved, as appropriate) of the determination or 
            reconsideration under time limitations established by the 
            Secretary, but not later than 72 hours of the time of 
            receipt of the request for the determination or 
            reconsideration (or receipt of the information necessary to 
            make the determination or reconsideration), or such longer 
            period as the Secretary may permit in specified cases.

         (4) Independent review of certain coverage denials

        The Secretary shall contract with an independent, outside entity 
    to review and resolve in a timely manner reconsiderations that 
    affirm denial of coverage, in whole or in part.

                             (5) Appeals

        An enrollee with a Medicare+Choice plan of a Medicare+Choice 
    organization under this part who is dissatisfied by reason of the 
    enrollee's failure to receive any health service to which the 
    enrollee believes the enrollee is entitled and at no greater charge 
    than the enrollee believes the enrollee is required to pay 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 
    405(b) of this title, and in any such hearing the Secretary shall 
    make the organization a party. If the amount in controversy is 
    $1,000 or more, the individual or organization shall, upon notifying 
    the other party, be entitled to judicial review of the Secretary's 
    final decision as provided in section 405(g) of this title, and both 
    the individual and the organization shall be entitled to be parties 
    to that judicial review. In applying subsections (b) and (g) of 
    section 405 of this title as provided in this paragraph, and in 
    applying section 405(l) of this title 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.

(h) Confidentiality and accuracy of enrollee records

    Insofar as a Medicare+Choice organization maintains medical records 
or other health information regarding enrollees under this part, the 
Medicare+Choice organization shall establish procedures--
        (1) to safeguard the privacy of any individually identifiable 
    enrollee information;
        (2) to maintain such records and information in a manner that is 
    accurate and timely; and
        (3) to assure timely access of enrollees to such records and 
    information.

(i) Information on advance directives

    Each Medicare+Choice organization shall meet the requirement of 
section 1395cc(f) of this title (relating to maintaining written 
policies and procedures respecting advance directives).

(j) Rules regarding provider participation

                           (1) Procedures

        Insofar as a Medicare+Choice organization offers benefits under 
    a Medicare+Choice plan through agreements with physicians, the 
    organization shall establish reasonable procedures relating to the 
    participation (under an agreement between a physician and the 
    organization) of physicians under such a plan. Such procedures shall 
    include--
            (A) providing notice of the rules regarding participation,
            (B) providing written notice of participation decisions that 
        are adverse to physicians, and
            (C) providing a process within the organization for 
        appealing such adverse decisions, including the presentation of 
        information and views of the physician regarding such decision.

                (2) Consultation in medical policies

        A Medicare+Choice organization shall consult with physicians who 
    have entered into participation agreements with the organization 
    regarding the organization's medical policy, quality, and medical 
    management procedures.

        (3) Prohibiting interference with provider advice to 
                                  enrollees

        (A) In general

            Subject to subparagraphs (B) and (C), a Medicare+Choice 
        organization (in relation to an individual enrolled under a 
        Medicare+
        Choice plan offered by the organization under this part) 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 plan, 
        if the professional is acting within the lawful scope of 
        practice.

        (B) Conscience protection

            Subparagraph (A) shall not be construed as requiring a 
        Medicare+Choice plan to provide, reimburse for, or provide 
        coverage of a counseling or referral service if the Medicare+
        Choice organization offering the plan--
                (i) objects to the provision of such service on moral or 
            religious grounds; and
                (ii) in the manner and through the written 
            instrumentalities such Medicare+
            Choice organization deems appropriate, makes available 
            information on its policies regarding such service to 
            prospective enrollees before or during enrollment and to 
            enrollees within 90 days after the date that the 
            organization or plan adopts a change in policy regarding 
            such a counseling or referral service.

        (C) Construction

            Nothing in subparagraph (B) shall be construed to affect 
        disclosure requirements under State law or under the Employee 
        Retirement Income Security Act of 1974 [29 U.S.C. 1001 et seq.].

        (D) ``Health care professional'' defined

            For purposes of this paragraph, the term ``health care 
        professional'' means a physician (as defined in section 1395x(r) 
        of this title) or other health care professional if coverage for 
        the professional's services is provided under the 
        Medicare+Choice plan 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-language 
        pathologist, audiologist, registered or licensed practical nurse 
        (including nurse practitioner, clinical nurse specialist, 
        certified registered nurse anesthetist, and certified nurse-
        midwife), licensed certified social worker, registered 
        respiratory therapist, and certified respiratory therapy 
        technician.

            (4) Limitations on physician incentive plans

        (A) In general

            No Medicare+Choice organization may operate any physician 
        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 physician or physician 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 physician or physician group 
            at substantial financial risk (as determined by the 
            Secretary) for services not provided by the physician or 
            physician group, the organization--
                    (I) provides stop-loss protection for the physician 
                or group that is adequate and appropriate, based on 
                standards developed by the Secretary that take into 
                account the number of physicians 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 physician or 
                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) ``Physician incentive plan'' defined

            In this paragraph, the term ``physician incentive plan'' 
        means any compensation arrangement between a Medicare+Choice 
        organization and a physician or physician group that may 
        directly or indirectly have the effect of reducing or limiting 
        services provided with respect to individuals enrolled with the 
        organization under this part.

             (5) Limitation on provider indemnification

        A Medicare+Choice organization may not provide (directly or 
    indirectly) for a health care professional, provider of services, or 
    other entity providing health care services (or group of such 
    professionals, providers, or entities) to indemnify the organization 
    against any liability resulting from a civil action brought for any 
    damage caused to an enrollee with a Medicare+Choice plan of the 
    organization under this part by the organization's denial of 
    medically necessary care.

       (6) Special rules for Medicare+Choice private fee-for-
                                service plans

        For purposes of applying this part (including subsection (k)(1) 
    of this section) and section 1395cc(a)(1)(O) of this title, a 
    hospital (or other provider of services), a physician or other 
    health care professional, or other entity furnishing health care 
    services is treated as having an agreement or contract in effect 
    with a Medicare+Choice organization (with respect to an individual 
    enrolled in a Medicare+Choice private fee-for-service plan it 
    offers), if--
            (A) the provider, professional, or other entity furnishes 
        services that are covered under the plan to such an enrollee; 
        and
            (B) before providing such services, the provider, 
        professional, or other entity--
                (i) has been informed of the individual's enrollment 
            under the plan, and
                (ii) either--
                    (I) has been informed of the terms and conditions of 
                payment for such services under the plan, or
                    (II) is given a reasonable opportunity to obtain 
                information concerning such terms and conditions,

          in a manner reasonably designed to effect informed agreement 
            by a provider.

    The previous sentence shall only apply in the absence of an explicit 
    agreement between such a provider, professional, or other entity and 
    the Medicare+Choice organization.

(k) Treatment of services furnished by certain providers

                           (1) In general

        Except as provided in paragraph (2), a physician or other entity 
    (other than a provider of services) that does not have a contract 
    establishing payment amounts for services furnished to an individual 
    enrolled under this part with a Medicare+Choice organization 
    described in section 1395w-21(a)(2)(A) of this title shall accept as 
    payment in full for covered services under this subchapter that are 
    furnished to such an individual the amounts that the physician or 
    other entity could collect if the individual were not so enrolled. 
    Any penalty or other provision of law that applies to such a payment 
    with respect to an individual entitled to benefits under this 
    subchapter (but not enrolled with a Medicare+Choice organization 
    under this part) also applies with respect to an individual so 
    enrolled.

     (2) Application to Medicare+Choice private fee-for-service 
                                    plans

        (A) Balance billing limits under Medicare+
                Choice private fee-for-service plans in case of contract 
                providers

            (i) In general

                In the case of an individual enrolled in a 
            Medicare+Choice private fee-for-service plan under this 
            part, a physician, provider of services, or other entity 
            that has a contract (including through the operation of 
            subsection (j)(6) of this section) establishing a payment 
            rate for services furnished to the enrollee shall accept as 
            payment in full for covered services under this subchapter 
            that are furnished to such an individual an amount not to 
            exceed (including any deductibles, coinsurance, copayments, 
            or balance billing otherwise permitted under the plan) an 
            amount equal to 115 percent of such payment rate.
            (ii) Procedures to enforce limits

                The Medicare+Choice organization that offers such a plan 
            shall establish procedures, similar to the procedures 
            described in section 1395w-4(g)(1)(A) of this title, in 
            order to carry out the previous sentence.
            (iii) Assuring enforcement

                If the Medicare+Choice organization fails to establish 
            and enforce procedures required under clause (ii), the 
            organization is subject to intermediate sanctions under 
            section 1395w-27(g) of this title.

        (B) Enrollee liability for noncontract providers

            For provision--
                (i) establishing minimum payment rate in the case of 
            noncontract providers under a Medicare+Choice private fee-
            for-service plan, see subsection (a)(2) of this section; or
                (ii) limiting enrollee liability in the case of covered 
            services furnished by such providers, see paragraph (1) and 
            section 1395cc(a)(1)(O) of this title.

        (C) Information on beneficiary liability

            (i) In general

                Each Medicare+Choice organization that offers a 
            Medicare+Choice private fee-for-service plan shall provide 
            that enrollees under the plan who are furnished services for 
            which payment is sought under the plan are provided an 
            appropriate explanation of benefits (consistent with that 
            provided under parts A and B of this subchapter and, if 
            applicable, under medicare supplemental policies) that 
            includes a clear statement of the amount of the enrollee's 
            liability (including any liability for balance billing 
            consistent with this subsection) with respect to payments 
            for such services.
            (ii) Advance notice before receipt of inpatient 
                    hospital services and certain other services

                In addition, such organization shall, in its terms and 
            conditions of payments to hospitals for inpatient hospital 
            services and for other services identified by the Secretary 
            for which the amount of the balance billing under 
            subparagraph (A) could be substantial, require the hospital 
            to provide to the enrollee, before furnishing such services 
            and if the hospital imposes balance billing under 
            subparagraph (A)--
                    (I) notice of the fact that balance billing is 
                permitted under such subparagraph for such services, and
                    (II) a good faith estimate of the likely amount of 
                such balance billing (if any), with respect to such 
                services, based upon the presenting condition of the 
                enrollee.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1852, as added Pub. L. 105-
33, title IV, Sec. 4001, Aug. 5, 1997, 111 Stat. 286; amended Pub. L. 
106-113, div. B, Sec. 1000(a)(6) [title III, Sec. 321(k)(6)(B), title V, 
Secs. 518, 520(a)], Nov. 29, 1999, 113 Stat. 1536, 1501A-367, 1501A-384, 
1501A-385.)

                       References in Text

    Part A of subchapter XI of this chapter, referred to in subsec. 
(a)(1)(A), is classified to section 1301 et seq. of this title.
    Parts A and B of this subchapter, referred to in subsecs. (a)(1)(A), 
(2)(A)(ii), (d)(4)(A), and (k)(2)(C)(i), are classified to sections 
1395c et seq. and 1395j et seq., respectively, of this title.
    The Employee Retirement Income Security Act of 1974, referred to in 
subsec. (j)(3)(C), is Pub. L. 93-406, Sept. 2, 1974, 88 Stat. 832, as 
amended, which is classified principally to chapter 18 (Sec. 1001 et 
seq.) of Title 29, Labor. For complete classification of this Act to the 
Code, see Short Title note set out under section 1001 of Title 29 and 
Tables.


                               Amendments

    1999--Subsec. (a)(3)(A). Pub. L. 106-113, Sec. 1000(a)(6) [title 
III, Sec. 321(k)(6)(B)(i)], struck out comma after ``MSA plan'' and 
inserted comma after ``the coverage)''.
    Subsec. (e)(2)(A). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 520(a)(1)], substituted ``, a non-network MSA plan, or a preferred 
provider organization plan'' for ``or a non-network MSA plan'' in 
introductory provisions.
    Subsec. (e)(2)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 520(a)(2)], substituted ``, non-network MSA plans, and preferred 
provider organization plans'' for ``and non-network MSA plans'' in 
heading and ``, a non-network MSA plan, or a preferred provider 
organization plan'' for ``or a non-network MSA plan'' in introductory 
provisions.
    Subsec. (e)(2)(D). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 520(a)(3)], added subpar. (D).
    Subsec. (e)(4). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 518], amended heading and text of par. (4) generally. Prior to 
amendment, text read as follows: ``The Secretary shall provide that a 
Medicare+Choice organization is deemed to meet requirements of 
paragraphs (1) and (2) of this subsection and subsection (h) of this 
section (relating to confidentiality and accuracy of enrollee records) 
if the organization is accredited (and periodically reaccredited) by a 
private organization under a process that the Secretary has determined 
assures that the organization, as a condition of accreditation, applies 
and enforces standards with respect to the requirements involved that 
are no less stringent than the standards established under section 
1395w-26 of this title to carry out the respective requirements.''
    Subsec. (g)(1)(B). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(6)(B)(ii)(I)], inserted ``or'' after ``in whole''.
    Subsec. (g)(3)(B)(ii). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(6)(B)(ii)(II)], inserted period at end.
    Subsec. (h)(2). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(6)(B)(iii)], substituted a semicolon for a comma before 
``and''.
    Subsec. (k)(2)(C)(ii). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(6)(B)(iv)], substituted ``balance'' for ``balancing'' before 
``billing under subparagraph (A) could'' in introductory provisions.


                    Effective Date of 1999 Amendment

    Amendment by section 1000(a)(6) [title III, Sec. 321(k)(6)(B)] of 
Pub. L. 106-113 effective as if included in the enactment of the 
Balanced Budget Act of 1997, Pub. L. 105-33, except as otherwise 
provided, see section 1000(a)(6) [title III, Sec. 321(m)] of Pub. L. 
106-113, set out as a note under section 1395d of this title.
    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 520(b)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-386, provided that: ``The 
amendments made by subsection (a) [amending this section] apply to 
contract years beginning on or after January 1, 2000.''


  Transitional Pass-Through of Additional Costs Under Medicare+Choice 
                            Program for 2000

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title II, Sec. 227(c)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-355, provided that: ``The 
provisions of subparagraphs (A) and (B) of section 1852(a)(5) of the 
Social Security Act (42 U.S.C. 1395w-22(a)(5)) shall apply with respect 
to the coverage of additional benefits for immunosuppressive drugs under 
the amendments made by this section [amending sections 1395k and 1395x 
of this title] for drugs furnished in 2000 in the same manner as if such 
amendments constituted a national coverage determination described in 
the matter in such section before subparagraph (A).''

                  Section Referred to in Other Sections

    This section is referred to in sections 1395w-21, 1395w-23, 1395w-
24, 1395w-25, 1395w-27, 1395w-28, 1396u-2 of this title.
