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42 U.S.C. § 300e — Requirements of health maintenance organizations
Federal law — U.S. Code and appendices · legal_authorities
**(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 oppo
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Source location: Title 42, Chapter 6A, § 300e; chapter-6a-public-health-service.md
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**(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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300e–1/2&num=0&edition=prelim), 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) 11 See References in Text note below. 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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300e–1/2&num=0&edition=prelim)). 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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title26-section220/c/2&num=0&edition=prelim)).
**(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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396&num=0&edition=prelim) 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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300gg–91/e&num=0&edition=prelim)), an affiliation period consistent with the provisions of section 2701(g).1
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Establishment** There is hereby established the Medicaid and CHIP Payment and Access Commission (in this section referred to as “MACPAC”).
**(b) Duties**
(1) **Review of access policies for all States and annual reports** — MACPAC shall—
(A) review policies of the Medicaid program established under this subchapter (in this section referred to as “Medicaid”) and the State Children’s Health Insurance Program established under subchapter XXI (in this section referred to as “CHIP”) affecting access to covered items and services, including topics described in paragraph (2);
(B) make recommendations to Congress, the Secretary, and States concerning such access policies;
(C) by not later than March 15 of each year (beginning with 2010), submit a report to Congress containing the results of such reviews and MACPAC’s recommendations concerning such policies; and
(D) by not later than June 15 of each year (beginning with 2010), submit a report to Congress containing an examination of issues affecting Medicaid and CHIP, including the implications of changes in health care delivery in the United States and in the market for health care services on such programs.
(2) **Specific topics to be reviewed** — Specifically, MACPAC shall review and assess the following:
(A) *Medicaid and CHIP payment policies* — Payment policies under Medicaid and CHIP, including—
(i) the factors affecting expenditures for the efficient provision of items and services in different sectors, including the process for updating payments to medical, dental, and health professionals, hospitals, residential and long-term care providers, providers of home and community based services, Federally-qualified health centers and rural health clinics, managed care entities, and providers of ot
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1396
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Federal law — U.S. Code and appendices · legal_authorities
Beginning with fiscal year 2010, the Secretary shall transfer from the Public Health and Social Services Emergency Fund such sums as may be necessary to carry out this part.
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Federal law — U.S. Code and appendices · legal_authorities
**(a) 11 So in original. No subsec. (b) has been enacted. Prohibiting discriminatory premium rates**
(1) **In general** — With respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual or small group market—
(A) such rate shall vary with respect to the particular plan or coverage involved only by—
(i) whether such plan or coverage covers an individual or family;
(ii) rating area, as established in accordance with paragraph (2);
(iii) age, except that such rate shall not vary by more than 3 to 1 for adults (consistent with [section 300gg–6(c) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300gg–6/c&num=0&edition=prelim)); and
(iv) tobacco use, except that such rate shall not vary by more than 1.5 to 1; and
(B) such rate shall not vary with respect to the particular plan or coverage involved by any other factor not described in subparagraph (A).
(2) **Rating area**
(A) *In general* — Each State shall establish 1 or more rating areas within that State for purposes of applying the requirements of this subchapter.
(B) *Secretarial review* — The Secretary shall review the rating areas established by each State under subparagraph (A) to ensure the adequacy of such areas for purposes of carrying out the requirements of this subchapter. If the Secretary determines a State’s rating areas are not adequate, or that a State does not establish such areas, the Secretary may establish rating areas for that State.
(3) **Permissible age bands** — The Secretary, in consultation with the National Association of Insurance Commissioners, shall define the permissible age bands for rating purposes under paragraph (1)(A)(iii).
(4) **Application of variat
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 300gg
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Federal law — U.S. Code and appendices · legal_authorities
This chapter may be cited as the “Social Security Act”.
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Federal law — U.S. Code and appendices · legal_authorities
**(a)** The Office of Personnel Management may contract with qualified carriers offering plans described by section 8903 or 8903a of this title, without regard to section 6101(b) to (d) of title 41 or other statute requiring competitive bidding. Each contract shall be for a uniform term of at least 1 year, but may be made automatically renewable from term to term in the absence of notice of termination by either party.
**(b)** To be eligible as a carrier for the plan described by [section 8903(2) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section8903/2&num=0&edition=prelim), a company must be licensed to issue group health insurance in all the States and the District of Columbia.
**(c)** A contract for a plan described by section 8903(1) or (2) of this title shall require the carrier—
(1) to reinsure with other companies which elect to participate, under an equitable formula based on the total amount of their group health insurance benefit payments in the United States during the latest year for which the information is available, to be determined by the carrier and approved by the Office; or
(2) to allocate its rights and obligations under the contract among its affiliates which elect to participate, under an equitable formula to be determined by the carrier and the affiliates and approved by the Office.
**(d)** Each contract under this chapter shall contain a detailed statement of benefits offered and shall include such maximums, limitations, exclusions, and other definitions of benefits as the Office considers necessary or desirable.
**(e)** The Office may prescribe reasonable minimum standards for health benefits plans described by section 8903 or 8903a of this title and for carriers offering the plans. Approval of a pla
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Separate accountability of assets and liabilities** To carry out the purposes set forth in paragraph (c) 11 See References in Text note below. of [section 1716 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title12-section1716&num=0&edition=prelim), the Association is authorized and directed, as of the close of the cutoff date determined by the Association pursuant to section 1718(d) 1 of this title, to establish separate accountability for all of its assets and liabilities (exclusive of capital, surplus, surplus reserves, and undistributed earnings to be evidenced by preferred stock as provided in section 1718(d) 1 of this title, but inclusive of all rights and obligations under any outstanding contracts), and to maintain such separate accountability for the management and orderly liquidation of such assets and liabilities as provided in this section.
**(b) Issuance of obligations to expedite substitution of private financing** For the purposes of this section and to assure that, to the maximum extent, and as rapidly as possible, private financing will be substituted for Treasury borrowings otherwise required to carry mortgages held under the aforesaid separate accountability, the Association is authorized to issue, upon the approval of the Secretary of the Treasury, and have outstanding at any one time obligations having such maturities and bearing such rate or rates of interest as may be determined by the Association with the approval of the Secretary of the Treasury, to be redeemable at the option of the Association before maturity in such manner as may be stipulated in such obligations; but in no event shall any such obligations be issued if, at the time of such proposed issuance, and as a consequence thereof, the resulting aggre
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Federal law — U.S. Code and appendices · legal_authorities
For purposes of this subchapter:
(1) The term “basic health services” means—
(A) physician services (including consultant and referral services by a physician);
(B) inpatient and outpatient hospital services;
(C) medically necessary emergency health services;
(D) short-term (not to exceed twenty visits), outpatient evaluative and crisis intervention mental health services;
(E) medical treatment and referral services (including referral services to appropriate ancillary services) for the abuse of or addiction to alcohol and drugs;
(F) diagnostic laboratory and diagnostic and therapeutic radiologic services;
(G) home health services; and
(H) preventive health services (including (i) immunizations, (ii) well-child care from birth, (iii) periodic health evaluations for adults, (iv) voluntary family planning services, (v) infertility services, and (vi) children’s eye and ear examinations conducted to determine the need for vision and hearing correction).
Such term does not include a health service which the Secretary, upon application of a health maintenance organization, determines is unusual and infrequently provided and not necessary for the protection of individual health. The Secretary shall publish in the Federal Register each determination made by him under the preceding sentence. If a service of a physician described in the preceding sentence may also be provided under applicable State law by a dentist, optometrist, podiatrist, psychologist, or other health care personnel, a health maintenance organization may provide such service through a dentist, optometrist, podiatrist, psychologist, or other health care personnel (as the case may be) licensed to provide such service. Such term includes a health service directly associated with an organ
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 300e–1
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Entities operating as health maintenance organizations** In the case of any entity—
(1) which cannot do business as a health maintenance organization in a State in which it proposes to furnish basic and supplemental health services because that State by law, regulation, or otherwise—
(A) requires as a condition to doing business in that State that a medical society approve the furnishing of services by the entity,
(B) requires that physicians constitute all or a percentage of its governing body,
(C) requires that all physicians or a percentage of physicians in the locale participate or be permitted to participate in the provision of services for the entity,
(D) requires that the entity meet requirements for insurers of health care services doing business in that State respecting initial capitalization and establishment of financial reserves against insolvency, or
(E) imposes requirements which would prohibit the entity from complying with the requirements of this subchapter, and
(2) for which a grant, contract, loan, or loan guarantee was made under this subchapter or which is a qualified health maintenance organization for purposes of [section 300e–9 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300e-9&num=0&edition=prelim) (relating to employees’ health benefits plans),
such requirements shall not apply to that entity so as to prevent it from operating as a health maintenance organization in accordance with [section 300e of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300e&num=0&edition=prelim).
**(b) Advertising** No State may establish or enforce any law which prevents a health maintenance organization for which a grant, contract, loan, or loan guarantee w
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 300e–10
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Determination of deficiency** If the Secretary determines that an entity which received a grant, contract, loan, or loan guarantee under this subchapter as a health maintenance organization or which was included in a health benefits plan offered to employees pursuant to [section 300e–9 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300e-9&num=0&edition=prelim)—
(1) fails to provide basic and supplemental services to its members,
(2) fails to provide such services in the manner prescribed by [section 300e(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300e/b&num=0&edition=prelim), or
(3) is not organized or operated in the manner prescribed by [section 300e(c) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300e/c&num=0&edition=prelim),
the Secretary may take the action authorized by subsection (b).
**(b) Action by Secretary upon determination**
(1) If the Secretary makes, with respect to any entity which provided assurances to the Secretary under section 300e–9(d)(1) 11 See References in Text note below. of this title, a determination described in subsection (a), the Secretary shall notify the entity in writing of the determination. Such notice shall specify the manner in which the entity has not complied with such assurances and direct that the entity initiate (within 30 days of the date the notice is issued by the Secretary or within such longer period as the Secretary determines is reasonable) such action as may be necessary to bring (within such period as the Secretary shall prescribe) the entity into compliance with the assurances. If the entity fails to initiate corrective action within the period prescribed by the notice
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 300e–11
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Authority** The Secretary may—
(1) make loans to public or private health maintenance organizations to assist them in meeting the amount by which their costs of operation during a period not to exceed the first sixty months of their operation exceed their revenues in that period;
(2) make loans to public or private health maintenance organizations to assist them in meeting the amount by which their costs of operation, which the Secretary determines are attributable to significant expansion in their membership or area served and which are incurred during a period not to exceed the first sixty months of their operation after such expansion, exceed their revenues in that period which the Secretary determines are attributable to such expansion; and
(3) guarantee to non-Federal lenders payment of the principal of and the interest on loans made to private health maintenance organizations for the amounts referred to in paragraphs (1) and (2).
No loan or loan guarantee may be made under this subsection for the costs of operation of a health maintenance organization unless the Secretary determines that the organization has made all reasonable attempts to meet such costs, and unless the Secretary has made a grant or loan to, entered into a contract with, or guaranteed a loan for, the organization in fiscal year 1981, 1982, 1983, 1984, or 1985 under this section or section 300e–3(b) 11 See References in Text note below. of this title (as in effect before October 1, 1985).
**(b) Limitations**
(1) Except as provided in paragraph (2), the aggregate amount of principal of loans made or guaranteed, or both, under subsection (a) for a health maintenance organization may not exceed $7,000,000. In any twelve-month period the amount disbursed to a health maintenance organization
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 300e–4
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