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42 U.S.C. § 300e — Requirements of health maintenance organizations

submitted 82 years ago by Pub. L. 93-222 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 2,269 words · no verdicts yet

in plain englishAI-generated · not legal advice

This section defines a 'health maintenance organization' (HMO) as an entity organized under state law. It must provide basic and supplemental health services the way subsection (b) requires. It must also be organized and run the way subsection (c) requires. Subsection (d) protects HMOs that offer certain affiliation periods.

(a) "Health maintenance organization" defined For this subchapter, a "health maintenance organization" (HMO) is a public or private organization set up under state law. To count as an HMO, it must do two things: (1) give its members basic and supplemental health services the way subsection (b) describes, and (2) organize and operate itself the way subsection (c) describes. (b) Manner of supplying basic and supplemental health services to members An HMO must give members basic and supplemental health services with no limits on timing or cost except what this subchapter allows. Here's how: (1) Basic health services payment. Each member gets basic health services for a payment that: (A) is paid on a regular schedule, no matter when services are actually used; (B) stays the same no matter how often or how much of a basic service a member actually uses; (C) must be set using a "community rating system" -- one rate for everyone in a rating group -- except for full-time college students, whose rate the Secretary of Health and Human Services treats differently; (D) can be supplemented by small extra charges for specific services, but only if those charges don't get in the way of members getting care. The Secretary sets the rules for these extra charges. If the HMO lets members see a doctor outside its normal staff arrangement (not the kind described in subsection (b)(3)(A)), it can also charge a reasonable deductible for using that doctor. An HMO may also choose to include a supplemental health service (as defined in section 300e-1(2)) within its basic package, covered by the same payment. If an HMO already provided prepaid comprehensive health care before it became a "qualified" HMO under section 300e-9(d), it doesn't have to follow the community-rating rule in (C) until 48 months after the month it became qualified. The basic-services-payment rules in this paragraph don't apply when a member is hurt or sick in a way covered by workers' compensation or an insurance policy -- but only to the extent that coverage applies. In those cases, the HMO may bill the workers' comp insurer, employer, or other paying party (or the member, if the member was already paid) for the services, following the payment rules set by that workers' comp law. Similarly, for injuries covered by an insurance policy, the HMO may bill the insurance carrier (or the member if already paid). (2) Supplemental health services payment. In exchange for extra payments (called "supplemental health services payments"), an HMO may give members supplemental health services (defined in section 300e-1(2)). If those extra payments are collected on a prepaid basis, they must also use a community rating system -- except for full-time college students, and except (for 48 months) for HMOs that provided prepaid comprehensive care before becoming qualified, as in paragraph (1). (3) Who can provide physician services. (A) At least 90% of the physician services counted as basic health services must come from: the HMO's own staff, a medical group, an individual practice association, contracted physicians or health professionals, or any combination of these. (B) That 90% rule doesn't apply to physician services that: (i) the HMO -- following the Secretary's rules -- decides are unusual or rarely used, or (ii) had to be provided a different way because of a medical emergency, before the member could get to the HMO's normal providers. (C) Contracts between the HMO and health professionals must include whatever terms the Secretary requires to ensure quality care and sound money management. (D) "Health professional" here means physicians, dentists, nurses, podiatrists, optometrists, and any other people the Secretary names by regulation. (4) Availability and accessibility. Within its service area, an HMO must make basic health services -- and any supplemental services a member has signed up for -- available promptly and reliably, and available 24/7 when medically necessary. Exception: an HMO serving only a non-metropolitan area may offer a basic service outside its area if that service isn't primary care or emergency care, and if there aren't enough providers of that service inside the area willing to serve the HMO's members. If a member needed basic or supplemental services urgently, for an unforeseen illness, injury, or condition, and got them outside the HMO, the HMO must reimburse the member's costs. (5) Disasters and emergencies. If a natural disaster, war, riot, civil unrest, or similar event outside the HMO's control (as the Secretary determines) keeps the HMO from providing services as required by paragraphs (1)-(4), the HMO only has to make a good-faith effort to provide those services within what its facilities, staff, and money can actually do. (6) High-deductible plans. An HMO that otherwise meets this subchapter's rules may offer a high-deductible health plan, as defined in section 220(c)(2) of title 26. (c) Organizational requirements Every HMO must: (1) (A) run a fiscally sound operation with adequate protection against becoming insolvent -- both satisfactory to the Secretary -- and (B) have management arrangements the Secretary finds satisfactory. (2) Take on full financial risk in advance for providing basic health services. Exceptions -- the HMO may: (A) buy insurance or make other arrangements for the cost, above $5,000 a year, of basic services given to any one member; (B) buy insurance or make arrangements for the cost of basic services a member got outside the HMO because they needed care right away, before the HMO could arrange it; (C) buy insurance or make arrangements covering up to 90% of the amount by which its yearly costs exceed 115% of its yearly income -- meaning: figure out 115% of the HMO's income for the year; if costs go above that, the HMO can insure up to nine-tenths of the extra amount; (D) arrange for physicians, other health professionals, or health care institutions to take on some or all of the financial risk themselves for the basic services they provide. (3) (A) Enroll members who broadly represent the different ages, social groups, and income levels in its service area. Exception: if the HMO serves a medically underserved population, no more than 75% of its members may come from that underserved population -- unless that population lives in a rural area (as the Secretary designates), in which case this cap doesn't apply. (B) Enroll Medicaid-eligible members (under a state plan approved under Title XIX of the Social Security Act) following the Secretary's approved procedures. (4) Never expel a member, or refuse to re-enroll one, because of the member's health status or need for health services. (5) Set up real, working procedures for hearing and settling disputes between the HMO (including its medical groups and other providers) and its members. (6) Have an ongoing quality-assurance program, set up under the Secretary's rules, that (A) focuses on health outcomes and (B) has physicians and other health professionals review how care was actually delivered. (7) Adopt at least one of these ways to protect members from having to personally pay bills that are legally the HMO's responsibility: (A) a contract with any hospital its members regularly use, banning that hospital from billing members for the HMO's debts; (B) insolvency insurance acceptable to the Secretary; (C) an adequate financial reserve acceptable to the Secretary; or (D) some other arrangement acceptable to the Secretary. This requirement doesn't apply if state law already protects members from this kind of liability. (8) Follow the Secretary's rules (which protect doctor-patient confidentiality) for developing, compiling, checking, and reporting statistics and information to the Secretary -- who publishes and shares this data yearly, and which the HMO must also share with its members and the public -- about: (A) its operating costs, (B) how its services are used, (C) how available, accessible, and acceptable its services are, (D) as far as practical, how its members' health is changing, and (E) any other matters the Secretary asks about. The Secretary must issue rules explaining when, in judging paragraph (1)(A) (fiscal soundness), the Secretary will consider the resources of a parent organization that owns or controls the HMO. Those rules must require the parent organization to give satisfactory assurance that it will cover the HMO's financial obligations, before its resources can be considered. (d) Application of rules by certain health maintenance organizations An organization offering health benefits doesn't fail to meet this section's requirements just because it offers an "affiliation period" -- a waiting period before coverage starts -- for coverage sold in the small- or large-group market (as section 300gg-91(e) defines those markets), as long as that affiliation period follows section 2701(g).
the actual law source: uscode.house.gov ↗public domain
(a) “Health maintenance organization” defined

For purposes of this subchapter, the term “health maintenance organization” means a public or private entity which is organized under the laws of any State and which (1) provides basic and supplemental health services to its members in the manner prescribed by subsection (b), and (2) is organized and operated in the manner prescribed by subsection (c).

(b) Manner of supplying basic and supplemental health services to members

A health maintenance organization shall provide, without limitations as to time or cost other than those prescribed by or under this subchapter, basic and supplemental health services to its members in the following manner:

(1)

Each member is to be provided basic health services for a basic health services payment which (A) is to be paid on a periodic basis without regard to the dates health services (within the basic health services) are provided; (B) is fixed without regard to the frequency, extent, or kind of health service (within the basic health services) actually furnished; (C) except in the case of basic health services provided a member who is a full-time student (as defined by the Secretary) at an accredited institution of higher education, is fixed under a community rating system; and (D) may be supplemented by additional nominal payments which may be required for the provision of specific services (within the basic health services), except that such payments may not be required where or in such a manner that they serve (as determined under regulations of the Secretary) as a barrier to the delivery of health services. Such additional nominal payments shall be fixed in accordance with the regulations of the Secretary. If a health maintenance organization offers to its members the opportunity to obtain basic health services through a physician not described in subsection (b)(3)(A), the organization may require, in addition to payments described in clause (D) of this paragraph, a reasonable deductible to be paid by a member when obtaining a basic health service from such a physician. A health maintenance organization may include a health service, defined as a supplemental health service by section 300e–1(2) of this title, in the basic health services provided its members for a basic health services payment described in the first sentence. In the case of an entity which before it became a qualified health maintenance organization (within the meaning of section 300e–9(d) 1 of this title) provided comprehensive health services on a prepaid basis, the requirement of clause (C) shall not apply to such entity until the expiration of the forty-eight month period beginning with the month following the month in which the entity became such a qualified health organization. The requirements of this paragraph respecting the basic health services payment shall not apply to the provision of basic health services to a member for an illness or injury for which the member is entitled to benefits under a workmen’s compensation law or an insurance policy but only to the extent such benefits apply to such services. For the provision of such services for an illness or injury for which a member is entitled to benefits under such a law, the health maintenance organization may, if authorized by such law, charge or authorize the provider of such services to charge, in accordance with the charges allowed under such law, the insurance carrier, employer, or other entity which under such law is to pay for the provision of such services or, to the extent that such member has been paid under such law for such services, such member. For the provision of such services for an illness or injury for which a member is entitled to benefits under an insurance policy, a health maintenance organization may charge or authorize the provider of such services to charge the insurance carrier under such policy or, to the extent that such member has been paid under such policy for such services, such member.

(2)

For such payment or payments (hereinafter in this subchapter referred to as “supplemental health services payments”) as the health maintenance organization may require in addition to the basic health services payment, the organization may provide to each of its members any of the health services which are included in supplemental health services (as defined in section 300e–1(2) of this title). Supplemental health services payments which are fixed on a prepayment basis shall be fixed under a community rating system unless the supplemental health services payment is for a supplemental health service provided a member who is a full-time student (as defined by the Secretary) at an accredited institution of higher education, except that, in the case of an entity which before it became a qualified health maintenance organization (within the meaning of section 300e–9(d) 1 of this title) provided comprehensive health services on a prepaid basis, the requirement of this sentence shall not apply to such entity during the forty-eight month period beginning with the month following the month in which the entity became such a qualified health maintenance organization.

(3)
(A)

Except as provided in subparagraph (B), at least 90 percent of the services of a physician which are provided as basic health services shall be provided through—

(i)

members of the staff of the health maintenance organization,

(ii)

a medical group (or groups),

(iii)

an individual practice association (or associations),

(iv)

physicians or other health professionals who have contracted with the health maintenance organization for the provision of such services, or

(v)

any combination of such staff, medical group (or groups), individual practice association (or associations) or physicians or other health professionals under contract with the organization.

(B)

Subparagraph (A) does not apply to the provision of the services of a physician—

(i)

which the health maintenance organization determines, in conformity with regulations of the Secretary, are unusual or infrequently used, or

(ii)

which are provided a member of the organization in a manner other than that prescribed by subparagraph (A) because of an emergency which made it medically necessary that the service be provided to the member before it could be provided in a manner prescribed by subparagraph (A).

(C)

Contracts between a health maintenance organization and health professionals for the provision of basic and supplemental health services shall include such provisions as the Secretary may require, but only to the extent that such requirements are designed to insure the delivery of quality health care services and sound fiscal management.

(D)

For purposes of this paragraph the term “health professional” means physicians, dentists, nurses, podiatrists, optometrists, and such other individuals engaged in the delivery of health services as the Secretary may by regulation designate.

(4)

Basic health services (and only such supplemental health services as members have contracted for) shall within the area served by the health maintenance organization be available and accessible to each of its members with reasonable promptness and in a manner which assures continuity, and when medically necessary be available and accessible twenty-four hours a day and seven days a week, except that a health maintenance organization which has a service area located wholly in a nonmetropolitan area may make a basic health service available outside its service area if that basic health service is not a primary care or emergency health care service and if there is an insufficient number of providers of that basic health service within the service area who will provide such service to members of the health maintenance organization. A member of a health maintenance organization shall be reimbursed by the organization for his expenses in securing basic and supplemental health services other than through the organization if the services were medically necessary and immediately required because of an unforeseen illness, injury, or condition.

(5)

To the extent that a natural disaster, war, riot, civil insurrection, or any other similar event not within the control of a health maintenance organization (as determined under regulations of the Secretary) results in the facilities, personnel, or financial resources of a health maintenance organization not being available to provide or arrange for the provision of a basic or supplemental health service in accordance with the requirements of paragraphs (1) through (4) of this subsection, such requirements only require the organization to make a good-faith effort to provide or arrange for the provision of such service within such limitation on its facilities, personnel, or resources.

(6)

A health maintenance organization that otherwise meets the requirements of this subchapter may offer a high-deductible health plan (as defined in section 220(c)(2) of title 26).

(c) Organizational requirements

Each health maintenance organization shall—

(1)
(A)

have—

(i)

a fiscally sound operation, and

(ii)

adequate provision against the risk of insolvency,

which is satisfactory to the Secretary, and (B) have administrative and managerial arrangements satisfactory to the Secretary;

(2)

assume full financial risk on a prospective basis for the provision of basic health services, except that a health maintenance organization may (A) obtain insurance or make other arrangements for the cost of providing to any member basic health services the aggregate value of which exceeds $5,000 in any year, (B) obtain insurance or make other arrangements for the cost of basic health services provided to its members other than through the organization because medical necessity required their provision before they could be secured through the organization, (C) obtain insurance or make other arrangements for not more than 90 per centum of the amount by which its costs for any of its fiscal years exceed 115 per centum of its income for such fiscal year, and (D) make arrangements with physicians or other health professionals, health care institutions, or any combination of such individuals or institutions to assume all or part of the financial risk on a prospective basis for the provision of basic health services by the physicians or other health professionals or through the institutions;

(3)
(A)

enroll persons who are broadly representative of the various age, social, and income groups within the area it serves, except that in the case of a health maintenance organization which has a medically underserved population located (in whole or in part) in the area it serves, not more than 75 per centum of the members of that organization may be enrolled from the medically underserved population unless the area in which such population resides is also a rural area (as designated by the Secretary), and (B) carry out enrollment of members who are entitled to medical assistance under a State plan approved under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] in accordance with procedures approved under regulations promulgated by the Secretary;

(4)

not expel or refuse to re-enroll any member because of his health status or his requirements for health services;

(5)

be organized in such a manner that provides meaningful procedures for hearing and resolving grievances between the health maintenance organization (including the medical group or groups and other health delivery entities providing health services for the organization) and the members of the organization;

(6)

have organizational arrangements, established in accordance with regulations of the Secretary, for an ongoing quality assurance program for its health services which program (A) stresses health outcomes, and (B) provides review by physicians and other health professionals of the process followed in the provision of health services;

(7)

adopt at least one of the following arrangements to protect its members from incurring liability for payment of any fees which are the legal obligation of such organization—

(A)

a contractual arrangement with any hospital that is regularly used by the members of such organization prohibiting such hospital from holding any such member liable for payment of any fees which are the legal obligation of such organization;

(B)

insolvency insurance, acceptable to the Secretary;

(C)

adequate financial reserve, acceptable to the Secretary; and

(D)

other arrangements, acceptable to the Secretary, to protect members,

except that the requirements of this paragraph shall not apply to a health maintenance organization if applicable State law provides the members of such organization with protection from liability for payment of any fees which are the legal obligation of such organization; and

(8)

provide, in accordance with regulations of the Secretary (including safeguards concerning the confidentiality of the doctor-patient relationship), and effective procedure for developing, compiling, evaluating, and reporting to the Secretary, statistics and other information (which the Secretary shall publish and disseminate on an annual basis and which the health maintenance organization shall disclose, in a manner acceptable to the Secretary, to its members and the general public) relating to (A) the cost of its operations, (B) the patterns of utilization of its services, (C) the availability, accessibility, and acceptability of its services, (D) to the extent practical, developments in the health status of its members, and (E) such other matters as the Secretary may require.

The Secretary shall issue regulations stating the circumstances under which the Secretary, in administering paragraph (1)(A), will consider the resources of an organization which owns or controls a health maintenance organization. Such regulations shall require as a condition to consideration of resources that an organization which owns or controls a health maintenance organization shall provide satisfactory assurances that it will assume the financial obligations of the health maintenance organization.

(d) Application of rules by certain health maintenance organizations

An organization that offers health benefits coverage shall not be considered as failing to meet the requirements of this section notwithstanding that it provides, with respect to coverage offered in connection with a group health plan in the small or large group market (as defined in section 300gg–91(e) of this title), an affiliation period consistent with the provisions of section 2701(g).1

Source credit: (July 1, 1944, ch. 373, title XIII, § 1301, as added Pub. L. 93–222, § 2, Dec. 29, 1973, 87 Stat. 914; amended Pub. L. 94–460, title I, §§ 101, 102(a), 103, 105(a), Oct. 8, 1976, 90 Stat. 1945–1947; Pub. L. 95–559, §§ 9(b), 10, 11(a)–(d), Nov. 1, 1978, 92 Stat. 2137–2139; Pub. L. 96–32, § 2(b), July 10, 1979, 93 Stat. 82; Pub. L. 97–35, title IX, § 942(a)(1), (2), (b)–(e), Aug. 13, 1981, 95 Stat. 573, 574; Pub. L. 100–517, §§ 2–4(a), 5(a)(1), (2), (b), Oct. 24, 1988, 102 Stat. 2578, 2579; Pub. L. 104–191, title I, §§ 102(b), 193, Aug. 21, 1996, 110 Stat. 1976, 1988.)

history & why it existsrecord from the source credit
  • 1944Enacted · Pub. L. 93-222 · 87 Stat. 914
  • 1976Amended · Pub. L. 94-460 · 90 Stat. 1945
  • 1978Amended · Pub. L. 95-559 · 92 Stat. 2137
  • 1979Amended · Pub. L. 96-32 · 93 Stat. 82
  • 1981Amended · Pub. L. 97-35 · 95 Stat. 573, 574
  • 1988Amended · Pub. L. 100-517 · 102 Stat. 2578, 2579
  • 1996Amended · Pub. L. 104-191 · 110 Stat. 1976, 1988

A history note hasn’t been published yet. The record shows enactment by Pub. L. 93-222 on 1944-07-01.

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