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U.S. Code as of:
01/19/04
Section 1396u-2. Provisions relating to managed care
(a) State option to use managed care
(1) Use of medicaid managed care organizations and primary care
case managers
(A) In general
Subject to the succeeding provisions of this section, and
notwithstanding paragraph (1), (10)(B), or (23)(A) of section
1396a(a) of this title, a State -
(i) may require an individual who is eligible for medical
assistance under the State plan under this subchapter to
enroll with a managed care entity as a condition of receiving
such assistance (and, with respect to assistance furnished by
or under arrangements with such entity, to receive such
assistance through the entity), if -
(I) the entity and the contract with the State meet the
applicable requirements of this section and section
1396b(m) of this title or section 1396d(t) of this title,
and
(II) the requirements described in the succeeding
paragraphs of this subsection are met; and
(ii) may restrict the number of provider agreements with
managed care entities under the State plan if such
restriction does not substantially impair access to services.
(B) "Managed care entity" defined
In this section, the term "managed care entity" means -
(i) a medicaid managed care organization, as defined in
section 1396b(m)(1)(A) of this title, that provides or
arranges for services for enrollees under a contract pursuant
to section 1396b(m) of this title; and
(ii) a primary care case manager, as defined in section
1396d(t)(2) of this title.
(2) Special rules
(A) Exemption of certain children with special needs
A State may not require under paragraph (1) the enrollment in
a managed care entity of an individual under 19 years of age
who -
(i) is eligible for supplemental security income under
subchapter XVI of this chapter;
(ii) is described in section 701(a)(1)(D) of this title;
(iii) is described in section 1396a(e)(3) of this title;
(iv) is receiving foster care or adoption assistance under
part E of subchapter IV of this chapter; or
(v) is in foster care or otherwise in an out-of-home
placement.
(B) Exemption of medicare beneficiaries
A State may not require under paragraph (1) the enrollment in
a managed care entity of an individual who is a qualified
medicare beneficiary (as defined in section 1396d(p)(1) of this
title) or an individual otherwise eligible for benefits under
subchapter XVIII of this chapter.
(C) Indian enrollment
A State may not require under paragraph (1) the enrollment in
a managed care entity of an individual who is an Indian (as
defined in section 4(c) of the Indian Health Care Improvement
Act of 1976 (25 U.S.C. 1603(c)) unless the entity is one of the
following (and only if such entity is participating under the
plan):
(i) The Indian Health Service.
(ii) An Indian health program operated by an Indian tribe
or tribal organization pursuant to a contract, grant,
cooperative agreement, or compact with the Indian Health
Service pursuant to the Indian Self-Determination Act [25
U.S.C. 450f et seq.].
(iii) An urban Indian health program operated by an urban
Indian organization pursuant to a grant or contract with the
Indian Health Service pursuant to title V of the Indian
Health Care Improvement Act [25 U.S.C. 1651 et seq.].
(3) Choice of coverage
(A) In general
A State must permit an individual to choose a managed care
entity from not less than two such entities that meet the
applicable requirements of this section, and of section
1396b(m) of this title or section 1396d(t) of this title.
(B) State option
At the option of the State, a State shall be considered to
meet the requirements of subparagraph (A) in the case of an
individual residing in a rural area, if the State requires the
individual to enroll with a managed care entity if such entity
-
(i) permits the individual to receive such assistance
through not less than two physicians or case managers (to the
extent that at least two physicians or case managers are
available to provide such assistance in the area), and
(ii) permits the individual to obtain such assistance from
any other provider in appropriate circumstances (as
established by the State under regulations of the Secretary).
(C) Treatment of certain county-operated health insuring
organizations
A State shall be considered to meet the requirement of
subparagraph (A) if -
(i) the managed care entity in which the individual is
enrolled is a health-insuring organization which -
(I) first became operational prior to January 1, 1986, or
(II) is described in section 9517(c)(3) of the Omnibus
Budget Reconciliation Act of 1985 (as added by section
4734(2) of the Omnibus Budget Reconciliation Act of 1990),
and
(ii) the individual is given a choice between at least two
providers within such entity.
(4) Process for enrollment and termination and change of
enrollment
As conditions under paragraph (1)(A) -
(A) In general
The State, enrollment broker (if any), and managed care
entity shall permit an individual eligible for medical
assistance under the State plan under this subchapter who is
enrolled with the entity under this subchapter to terminate (or
change) such enrollment -
(i) for cause at any time (consistent with section
1396b(m)(2)(A)(vi) of this title), and
(ii) without cause -
(I) during the 90-day period beginning on the date the
individual receives notice of such enrollment, and
(II) at least every 12 months thereafter.
(B) Notice of termination rights
The State shall provide for notice to each such individual of
the opportunity to terminate (or change) enrollment under such
conditions. Such notice shall be provided at least 60 days
before each annual enrollment opportunity described in
subparagraph (A)(ii)(II).
(C) Enrollment priorities
In carrying out paragraph (1)(A), the State shall establish a
method for establishing enrollment priorities in the case of a
managed care entity that does not have sufficient capacity to
enroll all such individuals seeking enrollment under which
individuals already enrolled with the entity are given priority
in continuing enrollment with the entity.
(D) Default enrollment process
In carrying out paragraph (1)(A), the State shall establish a
default enrollment process -
(i) under which any such individual who does not enroll
with a managed care entity during the enrollment period
specified by the State shall be enrolled by the State with
such an entity which has not been found to be out of
substantial compliance with the applicable requirements of
this section and of section 1396b(m) of this title or section
1396d(t) of this title; and
(ii) that takes into consideration -
(I) maintaining existing provider-individual
relationships or relationships with providers that have
traditionally served beneficiaries under this subchapter;
and
(II) if maintaining such provider relationships is not
possible, the equitable distribution of such individuals
among qualified managed care entities available to enroll
such individuals, consistent with the enrollment capacities
of the entities.
(5) Provision of information
(A) Information in easily understood form
Each State, enrollment broker, or managed care entity shall
provide all enrollment notices and informational and
instructional materials relating to such an entity under this
subchapter in a manner and form which may be easily understood
by enrollees and potential enrollees of the entity who are
eligible for medical assistance under the State plan under this
subchapter.
(B) Information to enrollees and potential enrollees
Each managed care entity that is a medicaid managed care
organization shall, upon request, make available to enrollees
and potential enrollees in the organization's service area
information concerning the following:
(i) Providers
The identity, locations, qualifications, and availability
of health care providers that participate with the
organization.
(ii) Enrollee rights and responsibilities
The rights and responsibilities of enrollees.
(iii) Grievance and appeal procedures
The procedures available to an enrollee and a health care
provider to challenge or appeal the failure of the
organization to cover a service.
(iv) Information on covered items and services
All items and services that are available to enrollees
under the contract between the State and the organization
that are covered either directly or through a method of
referral and prior authorization. Each managed care entity
that is a primary care case manager shall, upon request, make
available to enrollees and potential enrollees in the
organization's service area the information described in
clause (iii).
(C) Comparative information
A State that requires individuals to enroll with managed care
entities under paragraph (1)(A) shall annually (and upon
request) provide, directly or through the managed care entity,
to such individuals a list identifying the managed care
entities that are (or will be) available and information
(presented in a comparative, chart-like form) relating to the
following for each such entity offered:
(i) Benefits and cost-sharing
The benefits covered and cost-sharing imposed by the
entity.
(ii) Service area
The service area of the entity.
(iii) Quality and performance
To the extent available, quality and performance indicators
for the benefits under the entity.
(D) Information on benefits not covered under managed care
arrangement
A State, directly or through managed care entities, shall, on
or before an individual enrolls with such an entity under this
subchapter, inform the enrollee in a written and prominent
manner of any benefits to which the enrollee may be entitled to
under this subchapter but which are not made available to the
enrollee through the entity. Such information shall include
information on where and how such enrollees may access benefits
not made available to the enrollee through the entity.
(b) Beneficiary protections
(1) Specification of benefits
Each contract with a managed care entity under section 1396b(m)
of this title or under section 1396d(t)(3) of this title shall
specify the benefits the provision (or arrangement) for which the
entity is responsible.
(2) Assuring coverage to emergency services
(A) In general
Each contract with a medicaid managed care organization under
section 1396b(m) of this title and each contract with a primary
care case manager under section 1396d(t)(3) of this title shall
require the organization or manager -
(i) to provide coverage for emergency services (as defined
in subparagraph (B)) without regard to prior authorization or
the emergency care provider's contractual relationship with
the organization or manager, and
(ii) to comply with guidelines established under section
1395w-22(d)(2) of this title (respecting coordination of
post-stabilization care) in the same manner as such
guidelines apply to Medicare+Choice plans offered under part
C of subchapter XVIII of this chapter.
The requirement under clause (ii) shall first apply 30 days
after the date of promulgation of the guidelines referred to in
such clause.
(B) "Emergency services" defined
In subparagraph (A)(i), the term "emergency services" means,
with respect to an individual enrolled with an organization,
covered inpatient and outpatient services that -
(i) are furnished by a provider that is qualified to
furnish such services under this subchapter, and
(ii) are needed to evaluate or stabilize an emergency
medical condition (as defined in subparagraph (C)).
(C) "Emergency medical condition" defined
In subparagraph (B)(ii), 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.
(3) Protection of enrollee-provider communications
(A) In general
Subject to subparagraphs (B) and (C), under a contract under
section 1396b(m) of this title a medicaid managed care
organization (in relation to an individual enrolled under the
contract) shall not prohibit or otherwise restrict a covered
health care professional (as defined in subparagraph (D)) from
advising such an individual who is a patient of the
professional about the health status of the individual or
medical care or treatment for the individual's condition or
disease, regardless of whether benefits for such care or
treatment are provided under the contract, if the professional
is acting within the lawful scope of practice.
(B) Construction
Subparagraph (A) shall not be construed as requiring a
medicaid managed care organization to provide, reimburse for,
or provide coverage of, a counseling or referral service if the
organization -
(i) objects to the provision of such service on moral or
religious grounds; and
(ii) in the manner and through the written
instrumentalities such organization deems appropriate, makes
available information on its policies regarding such service
to prospective enrollees before or during enrollment and to
enrollees within 90 days after the date that the organization
adopts a change in policy regarding such a counseling or
referral service.
Nothing in this subparagraph shall be construed to affect
disclosure requirements under State law or under the Employee
Retirement Income Security Act of 1974 [29 U.S.C. 1001 et
seq.].
(C) "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 contract
referred to in subparagraph (A) for the services of the
professional. Such term includes a podiatrist, optometrist,
chiropractor, psychologist, dentist, physician assistant,
physical or occupational therapist and therapy assistant,
speech-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) Grievance procedures
Each medicaid 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
subchapter, or a provider on behalf of such an enrollee, may
challenge the denial of coverage of or payment for such
assistance.
(5) Demonstration of adequate capacity and services
Each medicaid managed care organization shall provide the State
and the Secretary with adequate assurances (in a time and manner
determined by the Secretary) that the organization, with respect
to a service area, has the capacity to serve the expected
enrollment in such service area, including assurances that the
organization -
(A) offers an appropriate range of services and access to
preventive and primary care services for the population
expected to be enrolled in such service area, and
(B) maintains a sufficient number, mix, and geographic
distribution of providers of services.
(6) Protecting enrollees against liability for payment
Each medicaid managed care organization shall provide that an
individual eligible for medical assistance under the State plan
under this subchapter who is enrolled with the organization may
not be held liable -
(A) for the debts of the organization, in the event of the
organization's insolvency,
(B) for services provided to the individual -
(i) in the event of the organization failing to receive
payment from the State for such services; or
(ii) in the event of a health care provider with a
contractual, referral, or other arrangement with the
organization failing to receive payment from the State or the
organization for such services, or
(C) for payments to a provider that furnishes covered
services under a contractual, referral, or other arrangement
with the organization in excess of the amount that would be
owed by the individual if the organization had directly
provided the services.
(7) Antidiscrimination
A medicaid managed care 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 an organization from
including providers only to the extent necessary to meet the
needs of the organization's enrollees or from establishing any
measure designed to maintain quality and control costs consistent
with the responsibilities of the organization.
(8) Compliance with certain maternity and mental health
requirements
Each medicaid managed care organization shall comply with the
requirements of subpart 2 of part A of title XXVII of the Public
Health Service Act [42 U.S.C. 300gg-4 et seq.] insofar as such
requirements apply and are effective with respect to a health
insurance issuer that offers group health insurance coverage.
(c) Quality assurance standards
(1) Quality assessment and improvement strategy
(A) In general
If a State provides for contracts with medicaid managed care
organizations under section 1396b(m) of this title, the State
shall develop and implement a quality assessment and
improvement strategy consistent with this paragraph. Such
strategy shall include the following:
(i) Access standards
Standards for access to care so that covered services are
available within reasonable timeframes and in a manner that
ensures continuity of care and adequate primary care and
specialized services capacity.
(ii) Other measures
Examination of other aspects of care and service directly
related to the improvement of quality of care (including
grievance procedures and marketing and information
standards).
(iii) Monitoring procedures
Procedures for monitoring and evaluating the quality and
appropriateness of care and services to enrollees that
reflect the full spectrum of populations enrolled under the
contract and that includes requirements for provision of
quality assurance data to the State using the data and
information set that the Secretary has specified for use
under part C of subchapter XVIII of this chapter or such
alternative data as the Secretary approves, in consultation
with the State.
(iv) Periodic review
Regular, periodic examinations of the scope and content of
the strategy.
(B) Standards
The strategy developed under subparagraph (A) shall be
consistent with standards that the Secretary first establishes
within 1 year after August 5, 1997. Such standards shall not
preempt any State standards that are more stringent than such
standards. Guidelines relating to quality assurance that are
applied under section 1396n(b)(1) of this title shall apply
under this subsection until the effective date of standards for
quality assurance established under this subparagraph.
(C) Monitoring
The Secretary shall monitor the development and
implementation of strategies under subparagraph (A).
(D) Consultation
The Secretary shall conduct activities under subparagraphs
(B) and (C) in consultation with the States.
(2) External independent review of managed care activities
(A) Review of contracts
(i) In general
Each contract under section 1396b(m) of this title with a
medicaid managed care organization shall provide for an
annual (as appropriate) external independent review conducted
by a qualified independent entity of the quality outcomes and
timeliness of, and access to, the items and services for
which the organization is responsible under the contract. The
requirement for such a review shall not apply until after the
date that the Secretary establishes the identification method
described in clause (ii).
(ii) Qualifications of reviewer
The Secretary, in consultation with the States, shall
establish a method for the identification of entities that
are qualified to conduct reviews under clause (i).
(iii) Use of protocols
The Secretary, in coordination with the National Governors'
Association, shall contract with an independent quality
review organization (such as the National Committee for
Quality Assurance) to develop the protocols to be used in
external independent reviews conducted under this paragraph
on and after January 1, 1999.
(iv) Availability of results
The results of each external independent review conducted
under this subparagraph shall be available to participating
health care providers, enrollees, and potential enrollees of
the organization, except that the results may not be made
available in a manner that discloses the identity of any
individual patient.
(B) Nonduplication of accreditation
A State may provide that, in the case of a medicaid managed
care organization that is accredited by a private independent
entity (such as those described in section 1395w-22(e)(4) of
this title) or that has an external review conducted under
section 1395w-22(e)(3) of this title, the external review
activities conducted under subparagraph (A) with respect to the
organization shall not be duplicative of review activities
conducted as part of the accreditation process or the external
review conducted under such section.
(C) Deemed compliance for medicare managed care organizations
At the option of a State, the requirements of subparagraph
(A) shall not apply with respect to a medicaid managed care
organization if the organization is an eligible organization
with a contract in effect under section 1395mm of this title or
a Medicare+ÐChoice organization with a contract in effect under
part C of subchapter XVIII of this chapter and the organization
has had a contract in effect under section 1396b(m) of this
title at least during the previous 2-year period.
(d) Protections against fraud and abuse
(1) Prohibiting affiliations with individuals debarred by Federal
agencies
(A) In general
A managed care entity may not knowingly -
(i) have a person described in subparagraph (C) as a
director, officer, partner, or person with beneficial
ownership of more than 5 percent of the entity's equity, or
(ii) have an employment, consulting, or other agreement
with a person described in such subparagraph for the
provision of items and services that are significant and
material to the entity's obligations under its contract with
the State.
(B) Effect of noncompliance
If a State finds that a managed care entity is not in
compliance with clause (i) or (ii) of subparagraph (A), the
State -
(i) shall notify the Secretary of such noncompliance;
(ii) may continue an existing agreement with the entity
unless the Secretary (in consultation with the Inspector
General of the Department of Health and Human Services)
directs otherwise; and
(iii) may not renew or otherwise extend the duration of an
existing agreement with the entity unless the Secretary (in
consultation with the Inspector General of the Department of
Health and Human Services) provides to the State and to
Congress a written statement describing compelling reasons
that exist for renewing or extending the agreement.
(C) Persons described
A person is described in this subparagraph if such person -
(i) is debarred, suspended, or otherwise excluded from
participating in procurement activities under the Federal
Acquisition Regulation or from participating in
nonprocurement activities under regulations issued pursuant
to Executive Order No. 12549 or under guidelines implementing
such order; or
(ii) is an affiliate (as defined in such Regulation) of a
person described in clause (i).
(2) Restrictions on marketing
(A) Distribution of materials
(i) In general
A managed care entity, with respect to activities under
this subchapter, may not distribute directly or through any
agent or independent contractor marketing materials within
any State -
(I) without the prior approval of the State, and
(II) that contain false or materially misleading
information.
The requirement of subclause (I) shall not apply with respect
to a State until such date as the Secretary specifies in
consultation with such State.
(ii) Consultation in review of market materials
In the process of reviewing and approving such materials,
the State shall provide for consultation with a medical care
advisory committee.
(B) Service market
A managed care entity shall distribute marketing materials to
the entire service area of such entity covered under the
contract under section 1396b(m) of this title or section
1396d(t)(3) of this title.
(C) Prohibition of tie-ins
A managed care entity, or any agency of such entity, may not
seek to influence an individual's enrollment with the entity in
conjunction with the sale of any other insurance.
(D) Prohibiting marketing fraud
Each managed care entity shall comply with such procedures
and conditions as the Secretary prescribes in order to ensure
that, before an individual is enrolled with the entity, the
individual is provided accurate oral and written information
sufficient to make an informed decision whether or not to
enroll.
(E) Prohibition of "cold-call" marketing
Each managed care entity shall not, directly or indirectly,
conduct door-to-door, telephonic, or other "cold-call"
marketing of enrollment under this subchapter.
(3) State conflict-of-interest safeguards in medicaid risk
contracting
A medicaid managed care organization may not enter into a
contract with any State under section 1396b(m) of this title
unless the State has in effect conflict-of-interest safeguards
with respect to officers and employees of the State with
responsibilities relating to contracts with such organizations or
to the default enrollment process described in subsection
(a)(4)(C)(ii) of this section that are at least as effective as
the Federal safeguards provided under section 423 of title 41,
against conflicts of interest that apply with respect to Federal
procurement officials with comparable responsibilities with
respect to such contracts.
(4) Use of unique physician identifier for participating
physicians
Each medicaid managed care organization shall require each
physician providing services to enrollees eligible for medical
assistance under the State plan under this subchapter to have a
unique identifier in accordance with the system established under
section 1320d-2(b) of this title.
(e) Sanctions for noncompliance
(1) Use of intermediate sanctions by the State to enforce
requirements
(A) In general
A State may not enter into or renew a contract under section
1396b(m) of this title unless the State has established
intermediate sanctions, which may include any of the types
described in paragraph (2), other than the termination of a
contract with a medicaid managed care organization, which the
State may impose against a medicaid managed care organization
with such a contract, if the organization -
(i) fails substantially to provide medically necessary
items and services that are required (under law or under such
organization's contract with the State) to be provided to an
enrollee covered under the contract;
(ii) imposes premiums or charges on enrollees in excess of
the premiums or charges permitted under this subchapter;
(iii) acts to discriminate among enrollees on the basis of
their health status or requirements for health care services,
including expulsion or refusal to reenroll an individual,
except as permitted by this subchapter, or engaging in any
practice that would reasonably be expected to have the effect
of denying or discouraging enrollment with the organization
by eligible individuals whose medical condition or history
indicates a need for substantial future medical services;
(iv) misrepresents or falsifies information that is
furnished -
(I) to the Secretary or the State under this subchapter;
or
(II) to an enrollee, potential enrollee, or a health care
provider under such subchapter; or
(v) fails to comply with the applicable requirements of
section 1396b(m)(2)(A)(x) of this title.
The State may also impose such intermediate sanction against a
managed care entity if the State determines that the entity
distributed directly or through any agent or independent
contractor marketing materials in violation of subsection
(d)(2)(A)(i)(II) of this section.
(B) Rule of construction
Clause (i) of subparagraph (A) shall not apply to the
provision of abortion services, except that a State may impose
a sanction on any medicaid managed care organization that has a
contract to provide abortion services if the organization does
not provide such services as provided for under the contract.
(2) Intermediate sanctions
The sanctions described in this paragraph are as follows:
(A) Civil money penalties as follows:
(i) Except as provided in clause (ii), (iii), or (iv), not
more than $25,000 for each determination under paragraph
(1)(A).
(ii) With respect to a determination under clause (iii) or
(iv)(I) of paragraph (1)(A), not more than $100,000 for each
such determination.
(iii) With respect to a determination under paragraph
(1)(A)(ii), double the excess amount charged in violation of
such subsection (and the excess amount charged shall be
deducted from the penalty and returned to the individual
concerned).
(iv) Subject to clause (ii), with respect to a
determination under paragraph (1)(A)(iii), $15,000 for each
individual not enrolled as a result of a practice described
in such subsection.
(B) The appointment of temporary management -
(i) to oversee the operation of the medicaid managed care
organization upon a finding by the State that there is
continued egregious behavior by the organization or there is
a substantial risk to the health of enrollees; or
(ii) to assure the health of the organization's enrollees,
if there is a need for temporary management while -
(I) there is an orderly termination or reorganization of
the organization; or
(II) improvements are made to remedy the violations found
under paragraph (1),
except that temporary management under this subparagraph may
not be terminated until the State has determined that the
medicaid managed care organization has the capability to
ensure that the violations shall not recur.
(C) Permitting individuals enrolled with the managed care
entity to terminate enrollment without cause, and notifying
such individuals of such right to terminate enrollment.
(D) Suspension or default of all enrollment of individuals
under this subchapter after the date the Secretary or the State
notifies the entity of a determination of a violation of any
requirement of section 1396b(m) of this title or this section.
(E) Suspension of payment to the entity under this subchapter
for individuals enrolled after the date the Secretary or State
notifies the entity of such a determination and until the
Secretary or State is satisfied that the basis for such
determination has been corrected and is not likely to recur.
(3) Treatment of chronic substandard entities
In the case of a medicaid managed care organization which has
repeatedly failed to meet the requirements of section 1396b(m) of
this title and this section, the State shall (regardless of what
other sanctions are provided) impose the sanctions described in
subparagraphs (B) and (C) of paragraph (2).
(4) Authority to terminate contract
(A) In general
In the case of a managed care entity which has failed to meet
the requirements of this part or a contract under section
1396b(m) or 1396d(t)(3) of this title, the State shall have the
authority to terminate such contract with the entity and to
enroll such entity's enrollees with other managed care entities
(or to permit such enrollees to receive medical assistance
under the State plan under this subchapter other than through a
managed care entity).
(B) Availability of hearing prior to termination of contract
A State may not terminate a contract with a managed care
entity under subparagraph (A) unless the entity is provided
with a hearing prior to the termination.
(C) Notice and right to disenroll in cases of termination
hearing
A State may -
(i) notify individuals enrolled with a managed care entity
which is the subject of a hearing to terminate the entity's
contract with the State of the hearing, and
(ii) in the case of such an entity, permit such enrollees
to disenroll immediately with the entity without cause.
(5) Other protections for managed care entities against sanctions
imposed by State
Before imposing any sanction against a managed care entity
other than termination of the entity's contract, the State shall
provide the entity with notice and such other due process
protections as the State may provide, except that a State may not
provide a managed care entity with a pre-termination hearing
before imposing the sanction described in paragraph (2)(B).
(f) Timeliness of payment
A contract under section 1396b(m) of this title with a medicaid
managed care organization shall provide that the organization shall
make payment to health care providers for items and services which
are subject to the contract and that are furnished to individuals
eligible for medical assistance under the State plan under this
subchapter who are enrolled with the organization on a timely basis
consistent with the claims payment procedures described in section
1396a(a)(37)(A) of this title, unless the health care provider and
the organization agree to an alternate payment schedule.
(g) Identification of patients for purposes of making DSH payments
Each contract with a managed care entity under section 1396b(m)
of this title or under section 1396d(t)(3) of this title shall
require the entity either -
(1) to report to the State information necessary to determine
the hospital services provided under the contract (and the
identity of hospitals providing such services) for purposes of
applying sections 1395ww(d)(5)(F) and 1396r-4 of this title; or
(2) to include a sponsorship code in the identification card
issued to individuals covered under this subchapter in order that
a hospital may identify a patient as being entitled to benefits
under this subchapter.
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