INCREASED BENEFICIARY PROTECTIONS.

SEC. 4704. INCREASED BENEFICIARY PROTECTIONS. (a) In General.—Section 1932, as added by section 4701(a), is amended by adding at the end the following: “(b) Beneficiary Protections.— “(1) Specification of benefits.—Each contract with a managed care entity under section 1903(m) or under section 1905(t)(3) 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 1903(m) and each contract with a primary care case manager under section 1905(t)(3) shall require the organization or manager— “(i) to provide coverage for emergency services (as defined in subparagraph (B)) without regard to prior 111 STAT. 496authorization or the emergency care provider’s contractual relationship with the organization or manager, and “(ii) to comply with guidelines established under section 1852(d)(2) (respecting coordination of post-stabilization care) in the same manner as such guidelines apply to Medicare+Choice plans offered under part C of title XVIII. 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 title, 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 1903(m) 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 111 STAT. 497enrollment 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. “(C) Health care professional defined.—For purposes of this paragraph, the term ‘health care professional’ means a physician (as defined in section 1861(r)) 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 title, 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 title 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 111 STAT. 498be 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 insofar as such requirements apply and are effective with respect to a health insurance issuer that offers group health insurance coverage.”. (b) Protection of Enrollees Against Balance Billing Through Subcontractors.—Section 1128B(d)(1) (42 U.S.C. 1320a–7b(d)(1)) is amended by inserting “(or, in the case of services provided to an individual enrolled with a medicaid managed care organization under title XIX under a contract under section 1903(m) or under a contractual, referral, or other arrangement under such contract, at a rate in excess of the rate permitted under such contract)” before the comma at the end.