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

Page 1209 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 300e 1 See References in Text note below. (B) Such trauma center utilizes a risk-ad- justed benchmarking system and metrics to measure performance, quality, and patient outcomes. (C) Such trauma center demonstrates a need for integrated military trauma care providers to maintain or improve the trau- ma clinical capability of such trauma cen- ter. (3) Major trauma The term ‘‘major trauma’’ means an injury that is greater than or equal to 15 on the in- jury severity score. (4) Military trauma team The term ‘‘military trauma team’’ means a complete military trauma team consisting of military trauma care providers. (5) Military trauma care provider The term ‘‘military trauma care provider’’ means a member of the Armed Forces who fur- nishes emergency, critical care, and other trauma acute care services (including a physi- cian, surgeon, physician assistant, nurse, nurse practitioner, respiratory therapist, flight paramedic, combat medic, or enlisted medical technician) or other military trauma care provider as the Secretary determines ap- propriate. (g) Authorization of appropriations To carry out this section, there is authorized to be appropriated $11,500,000 for each of fiscal years 2019 through 2023. (July 1, 1944, ch. 373, title XII, § 1291, as added Pub. L. 116–22, title II, § 204, June 24, 2019, 133 Stat. 915.) SUBCHAPTER XI—HEALTH MAINTENANCE ORGANIZATIONS § 300e. Requirements of health maintenance or- ganizations (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) pro- vides basic and supplemental health services to its members in the manner prescribed by sub- section (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 pro- vide, without limitations as to time or cost other than those prescribed by or under this sub- chapter, 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 pay- ment which (A) is to be paid on a periodic basis without regard to the dates health serv- ices (within the basic health services) are pro- vided; (B) is fixed without regard to the fre- quency, extent, or kind of health service (within the basic health services) actually fur- nished; (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 ac- credited institution of higher education, is fixed under a community rating system; and (D) may be supplemented by additional nomi- nal 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 man- ner that they serve (as determined under regu- lations of the Secretary) as a barrier to the de- livery 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 de- scribed in subsection (b)(3)(A), the organiza- tion may require, in addition to payments de- scribed in clause (D) of this paragraph, a rea- sonable deductible to be paid by a member when obtaining a basic health service from such a physician. A health maintenance orga- nization may include a health service, defined as a supplemental health service by section 300e–1(2) of this title, in the basic health serv- ices provided its members for a basic health services payment described in the first sen- tence. In the case of an entity which before it became a qualified health maintenance orga- nization (within the meaning of section 300e–9(d) 1 of this title) provided comprehensive health services on a prepaid basis, the require- ment of clause (C) shall not apply to such enti- ty until the expiration of the forty-eight month period beginning with the month fol- lowing the month in which the entity became such a qualified health organization. The re- quirements 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 work- men’s compensation law or an insurance pol- icy 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 au- thorize 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 ex- tent 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 bene- fits under an insurance policy, a health main- tenance organization may charge or authorize the provider of such services to charge the in- surance carrier under such policy or, to the ex- tent that such member has been paid under such policy for such services, such member. (2) For such payment or payments (herein- after in this subchapter referred to as ‘‘supple- mental health services payments’’) as the health maintenance organization may require in addition to the basic health services pay- Page 1210 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 300e ment, 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 mem- ber 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) pro- vided comprehensive health services on a pre- paid 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 enti- ty became such a qualified health mainte- nance organization. (3)(A) Except as provided in subparagraph (B), at least 90 percent of the services of a phy- sician which are provided as basic health serv- ices 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 profes- sionals 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 asso- ciation (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 organiza- tion determines, in conformity with regula- tions of the Secretary, are unusual or infre- quently used, or (ii) which are provided a member of the or- ganization in a manner other than that pre- scribed by subparagraph (A) because of an emergency which made it medically nec- essary 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, den- tists, 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 sup- plemental health services as members have contracted for) shall within the area served by the health maintenance organization be avail- able 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 non- metropolitan 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 mem- ber of a health maintenance organization shall be reimbursed by the organization for his ex- penses in securing basic and supplemental health services other than through the organi- zation if the services were medically necessary and immediately required because of an un- foreseen illness, injury, or condition. (5) To the extent that a natural disaster, war, riot, civil insurrection, or any other simi- lar 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 organiza- tion to make a good-faith effort to provide or arrange for the provision of such service with- in such limitation on its facilities, personnel, or resources. (6) A health maintenance organization that otherwise meets the requirements of this sub- chapter 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 arrange- ments satisfactory to the Secretary; (2) assume full financial risk on a prospec- tive basis for the provision of basic health services, except that a health maintenance or- ganization may (A) obtain insurance or make other arrangements for the cost of providing to any member basic health services the ag- gregate value of which exceeds $5,000 in any year, (B) obtain insurance or make other ar- rangements for the cost of basic health serv- ices provided to its members other than through the organization because medical ne- cessity 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 Page 1211 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 300e 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 prospec- tive basis for the provision of basic health services by the physicians or other health pro- fessionals or through the institutions; (3)(A) enroll persons who are broadly rep- resentative of the various age, social, and in- come groups within the area it serves, except that in the case of a health maintenance orga- nization 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 en- rolled from the medically underserved popu- lation unless the area in which such popu- lation resides is also a rural area (as des- ignated by the Secretary), and (B) carry out enrollment of members who are entitled to medical assistance under a State plan ap- proved under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] in accordance with procedures approved under regulations pro- mulgated by the Secretary; (4) not expel or refuse to re-enroll any mem- ber because of his health status or his require- ments for health services; (5) be organized in such a manner that pro- vides meaningful procedures for hearing and resolving grievances between the health main- tenance organization (including the medical group or groups and other health delivery en- tities providing health services for the organi- zation) and the members of the organization; (6) have organizational arrangements, estab- lished 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 profes- sionals of the process followed in the provision of health services; (7) adopt at least one of the following ar- rangements to protect its members from in- curring 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 mem- bers of such organization prohibiting such hospital from holding any such member lia- ble 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 para- graph shall not apply to a health maintenance organization if applicable State law provides the members of such organization with protec- tion from liability for payment of any fees which are the legal obligation of such organi- zation; and (8) provide, in accordance with regulations of the Secretary (including safeguards con- cerning the confidentiality of the doctor-pa- tient relationship), and effective procedure for developing, compiling, evaluating, and report- ing to the Secretary, statistics and other in- formation (which the Secretary shall publish and disseminate on an annual basis and which the health maintenance organization shall dis- close, in a manner acceptable to the Sec- retary, 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 accept- ability of its services, (D) to the extent prac- tical, 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 con- trols a health maintenance organization. Such regulations shall require as a condition to con- sideration of resources that an organization which owns or controls a health maintenance organization shall provide satisfactory assur- ances that it will assume the financial obliga- tions of the health maintenance organization. (d) Application of rules by certain health mainte- nance organizations An organization that offers health benefits coverage shall not be considered as failing to meet the requirements of this section notwith- standing that it provides, with respect to cov- erage offered in connection with a group health plan in the small or large group market (as de- fined in section 300gg–91(e) of this title), an af- filiation period consistent with the provisions of section 2701(g).1 (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.) Editorial Notes REFERENCES IN TEXT Section 300e–9(d) of this title, referred to in subsec. (b)(1), (2), was redesignated section 300e–9(c) of this title by Pub. L. 100–517, § 7(b), Oct. 24, 1988, 102 Stat. 2580. The Social Security Act, referred to in subsec. (c)(3)(B), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Title XIX of the Social Security Act is classified generally to subchapter XIX (§ 1396 et seq.) of chapter 7 of this title. For complete classification of this Act to the Code, see section 1305 of this title and Tables. Section 2701, referred to in subsec. (d), is a reference to section 2701 of act July 1, 1944. Section 2701, which was classified to section 300gg of this title, was renum- bered section 2704, effective for plan years beginning on or after Jan. 1, 2014, with certain exceptions, and amended, by Pub. L. 111–148, title I, §§ 1201(2), 1563(c)(1), formerly § 1562(c)(1), title X, § 10107(b)(1), Mar. 23, 2010, 124 Stat. 154, 264, 911, and was transferred to section 300gg–3 of this title. A new section 2701 of act July 1, 1944, related to fair health insurance premiums, was added, effective for plan years beginning on or after Jan. 1, 2014, and amended, by Pub. L. 111–148, title I, Page 1212 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 300e § 1201(4), title X, § 10103(a), Mar. 23, 2010, 124 Stat. 155, 892, and is classified to section 300gg of this title. CODIFICATION Amendment to subsec. (b)(3)(D) by section 942(b)(2) of Pub. L. 97–35 was executed before redesignation by sec- tion 942(a)(1)(B) of Pub. L. 97–35, to reflect the probable intent of Congress. AMENDMENTS 1996—Subsec. (b)(6). Pub. L. 104–191, § 193, added par. (6). Subsec. (d). Pub. L. 104–191, § 102(b), added subsec. (d). 1988—Subsec. (a). Pub. L. 100–517, § 2, substituted ‘‘public or private entity which is organized under the laws of any State and’’ for ‘‘legal entity’’. Subsec. (b)(1). Pub. L. 100–517, § 3, inserted after sec- ond sentence ‘‘If a health maintenance organization of- fers 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.’’ Subsec. (b)(3)(A). Pub. L. 100–517, § 4(a), substituted ‘‘at least 90 percent of the services of a physician’’ for ‘‘the services of a physician’’. Subsec. (c). Pub. L. 100–517, § 5(a)(2), inserted at end ‘‘The Secretary shall issue regulations stating the cir- cumstances under which the Secretary, in admin- istering paragraph (1)(A), will consider the resources of an organization which owns or controls a health main- tenance organization. Such regulations shall require as a condition to consideration of resources that an orga- nization which owns or controls a health maintenance organization shall provide satisfactory assurances that it will assume the financial obligations of the health maintenance organization.’’ Subsec. (c)(1)(A). Pub. L. 100–517, § 5(a)(1), amended subpar. (A) generally. Prior to amendment, subpar. (A) read as follows: ‘‘have a fiscally sound operation and adequate provision against the risk of insolvency which is satisfactory to the Secretary, and’’. Subsec. (c)(5) to (9). Pub. L. 100–517, § 5(b), redesig- nated pars. (6) to (9) as (5) to (8), respectively, and struck out former par. (5) which read as follows: ‘‘(A) in the case of a private health maintenance organization, be organized in such a manner that assures that (i) at least one-third of the membership of the policymaking body of the health maintenance organization will be members of the organization, and (ii) there will be eq- uitable representation on such body of members from medically underserved populations served by the orga- nization, and (B) in the case of a public health mainte- nance organization, have an advisory board to the pol- icymaking body of the public entity operating the or- ganization which board meets the requirements of clause (A) of this paragraph and to which may be dele- gated policymaking authority for the organization;’’. 1981—Subsec. (b)(3)(A)(iv). Pub. L. 97–35, § 942(a)(2), substituted ‘‘physicians’’ for ‘‘subject to subparagraph (C), physicians’’. Subsec. (b)(3)(B). Pub. L. 97–35, § 942(b)(1), substituted ‘‘(B)’’ for ‘‘(B)(i)’’, ‘‘(i)’’ for ‘‘(I)’’, and ‘‘(ii)’’ for ‘‘(II)’’ and struck out former cl. (ii) which related to the forty-eight-month period beginning after the month of qualification of a health maintenance organization. Subsec. (b)(3)(C). Pub. L. 97–35, § 942(a)(1), redesig- nated subpar. (D) as (C) and struck out former subpar. (C) which related to the expiration of the first four fis- cal years as a qualified organization. Subsec. (b)(3)(D). Pub. L. 97–35, § 942(b)(2), amended subpar. (D) generally. Prior to amendment, subpar. (D) read as follows: ‘‘Contracts between a health mainte- nance organization and health professionals for the provision of basic and supplemental health services shall include such provisions as the Secretary may re- quire (including provisions requiring appropriate con- tinuing education).’’ See Codification note above. Pub. L. 97–35, § 942(a)(1)(B), redesignated subpar. (E) as (D). Former subpar. (D) redesignated (C). Subsec. (b)(4). Pub. L. 97–35, § 942(c), substituted ‘‘with reasonable promptness’’ for ‘‘promptly as appropriate’’ and inserted ‘‘, except that a health maintenance orga- nization 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 pro- viders of that basic health service within the service area who will provide such service to members of the health maintenance organization’’ after ‘‘week’’. Subsec. (c). Pub. L. 97–35, § 942(d)(1), (e), in par. (2) substituted provisions specifying requirements with re- spect to insurance, etc., for provisions generalizing such insurance, etc., requirements, and added cl. (D), struck out par. (4) which related to open enrollment pe- riod, redesignated pars. (5) to (8) as (4) to (7), respec- tively, added par. (8), struck out pars. (9) and (10) which related to medical social and health education services, and continuing education, respectively, and redesig- nated par. (11) as (9). Subsec. (d). Pub. L. 97–35, § 942(d)(2), struck out sub- sec. (d) which related to requirements, etc., respecting open enrollment period. 1979—Subsec. (b)(3). Pub. L. 96–32 amended directory language of section 11(a) of Pub. L. 95–559 by sub- stituting reference to section ‘‘1301’’ for ‘‘1310’’ of the Public Health Service Act, as section to be amended, and required no change in text because amendment made by Pub. L. 95–559 had been executed to this sec- tion as the probable intent of Congress. 1978—Subsec. (b)(1). Pub. L. 95–559, §§ 10(a), 11(b), in- serted ‘‘except in the case of basic health services pro- vided a member who is a full-time student (as defined by the Secretary) at an accredited institution of higher education,’’ after ‘‘the requirement of clause (C)’’ and inserted provisions permitting the health maintenance organization to seek reimbursement for the cost of services provided to a member who is entitled to bene- fits under a workmen’s compensation law or insurance policy. Subsec. (b)(2). Pub. L. 95–559, § 10(a), inserted ‘‘unless the supplemental health services payment is for a sup- plemental health service provided a member who is a full-time student (as defined by the Secretary) at an accredited institution of higher education,’’ after ‘‘community rating system’’. Subsec. (b)(3). Pub. L. 95–559, § 11(a), as amended by Pub. L. 96–32, inserted provisions limiting the health maintenance organization from entering into contracts for health services with physicians other than members of the staff of the health maintenance organization, medical groups, or individual practice associations. Subsec. (b)(4). Pub. L. 95–559, § 11(c), substituted ‘‘basic and supplemental’’ for ‘‘basic or supplemental’’ and ‘‘if the services were medically necessary and im- mediately required because of an unforeseen illness, in- jury, or condition’’ for ‘‘if it was medically necessary that the services be provided before it could secure them through the organization’’. Subsec. (b)(5). Pub. L. 95–559, § 11(d), added par. (5). Subsec. (c)(1). Pub. L. 95–559, § 10(b), designated exist- ing provisions as subpar. (A) and added subpar. (B). Subsec. (c)(3). Pub. L. 95–559, § 9(b), designated exist- ing provisions as subpar. (A) and added subpar. (B). Subsec. (c)(6). Pub. L. 95–559, § 10(c), designated exist- ing provisions as subpar. (A), inserted ‘‘in the case of a private health maintenance organization,’’ before ‘‘be organized in such’’, and substituted ‘‘(i)’’ for ‘‘(A)’’ and ‘‘(ii)’’ for ‘‘(B)’’, and added subpar. (B). 1976—Subsec. (b)(1). Pub. L. 94–460, §§ 101(a), 105(a)(1), provided that 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 service payment described in the first sentence, and also provided that, in the case of an entity which before it became a qualified health maintenance orga- Page 1213 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 300e nization (within the meaning of section 300e–9(d) of this title) provided comprehensive health services on a pre- paid basis, the requirement of clause (C) would 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. Subsec. (b)(2). Pub. L. 94–460, §§ 101(b), 105(a)(2), sub- stituted ‘‘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)’’ for ‘‘the organization shall pro- vide to each of its members each health service (A) which is included in supplemental health services (as defined in section 300e–1(2) of this title), (B) for which the required health manpower are available in the area served by the organization, and (C) for the provision of which the member has contracted with the organiza- tion’’ and inserted ‘‘except that, in the case of an enti- ty which before it became a qualified health mainte- nance organization (within the meaning of section 300e–9(d) of this title) provided comprehensive health services on a prepaid basis, the requirement of this sen- tence 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’’ after ‘‘Supplemental health services payments which are fixed on a prepay- ment basis shall be fixed under a community rating system’’. Subsec. (b)(3). Pub. L. 94–460, § 102(a), inserted ref- erences to health professionals who have contracted with the health maintenance organization for the pro- vision of such services and to the combination of staff, medical groups, individual practice associations, or health professionals under contract with the health maintenance organization, and inserted provisions al- lowing a health maintenance organization, during the thirty-six month period beginning with the month fol- lowing the month in which the organization becomes a qualified health maintenance organization (within the meaning of section 300e–9(d) of this title), to provide basic and supplemental health services through an en- tity which but for the requirement of section 300e–1(4)(C)(i) of this title would be a medical group for purposes of this subchapter, directing that after the ex- piration of such period, the organization may provide basic or supplemental health services through such an entity only if authorized by the Secretary in accord- ance with regulations which take into consideration the unusual circumstances of such entity, directing that a health maintenance organization may not, in any of its fiscal years, enter into contracts with health professionals or entities other than medical groups or individual practice associations if the amounts paid under such contracts for basic and supplemental health services exceed fifteen percent of the total amount to be paid in such fiscal year by the health maintenance organization to physicians for the provision of basic and supplemental health services, or, if the health maintenance organization principally serves a rural area, thirty percent of such amount, except that the sentence would not apply to the entering into of con- tracts for the purchase of basic and supplemental health services through an entity which but for the re- quirements of section 300e–1(4)(C)(i) of this title would be a medical group for purposes of this subchapter, and directing that contracts between a health maintenance organization and health professionals for the provision of basic and supplemental health services include such provisions as the Secretary may require (including pro- visions requiring appropriate continuing education). Subsec. (b)(4). Pub. L. 94–460, § 101(c), substituted ‘‘and only such supplemental health services as members have contracted for’’ for ‘‘and supplemental health services in the case of the members who have con- tracted therefor’’. Subsec. (c)(4). Pub. L. 94–460, § 103(a), substituted pro- visions making a simple reference to an open enroll- ment period in accordance with the provisions of sub- sec. (d) of this section for provisions spelling out in de- tail the requirements for a health maintenance organi- zation with regard to an open enrollment period. Subsec. (d). Pub. L. 94–460, § 103(b), added subsec. (d). Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 1976 AMENDMENT Pub. L. 94–460, title I, § 118, Oct. 8, 1976, 90 Stat. 1955, provided that: ‘‘(a) Except as provided in subsection (b), the amend- ments made by this title [enacting section 300e–15 of this title and amending this section, sections 300e–1 to 300e–11, 300e–13, and 300n–1 of this title, and section 8902 of Title 5, Government Organization and Employees] shall take effect on the date of the enactment of this Act [Oct. 8, 1976]. ‘‘(b)(1) The amendments made by sections 101 [amend- ing this section], 102 [amending this section and section 300e–1 of this title], 103 [amending this section], 104 [amending section 300e–1 of this title], and 106 [amend- ing section 300e–1 of this title] shall (A) apply with re- spect to grants, contracts, loans, and loan guarantees made under sections 1303, 1304, and 1305 of the Public Health Service Act [42 U.S.C. 300e–2, 300e–3, 300e–4] for fiscal years beginning after September 30, 1976, (B) apply with respect to health benefit plans offered under section 1310 of such Act [42 U.S.C. 300e–9] after such date, and (C) for purposes of section 1312 [42 U.S.C. 300e–11] take effect October 1, 1976. ‘‘(2) Subsection (d) of section 1301 of the Public Health Service Act [42 U.S.C. 300e(d)] (added by section 103(b) of this Act) shall take effect with respect to fis- cal years of health maintenance organizations begin- ning on or after the date of the enactment of this Act [Oct. 8, 1976]. ‘‘(3) The amendments made by section 107 [amending sections 300e–2, 300e–3, and 300e–4 of this title] shall apply with respect to grants, contracts, loans, and loan guarantees made under sections 1303, 1304, and 1305 of the Public Health Service Act [42 U.S.C. 300e–2, 300e–3, 300e–4] for fiscal years beginning after September 30, 1976. ‘‘(4) The amendments made by sections 109(a)(1) [amending section 300e–4 of this title] and 109(c) [amending section 300e–7 of this title] shall apply with respect to loan guarantees made under section 1305 of the Public Health Service Act [42 U.S.C. 300e–4] after September 30, 1976. ‘‘(5) The amendment made by section 109(e) [amend- ing section 300e–3 of this title] shall apply with respect to projects assisted under section 1304 of the Public Health Service Act [42 U.S.C. 300e–3] after September 30, 1976. ‘‘(6) The amendments made by paragraphs (1) and (2) of section 110(a) [amending section 300e–9 of this title] shall apply with respect to calendar quarters which begin after the date of the enactment of this Act [Oct. 8, 1976]. ‘‘(7) The amendments made by paragraphs (3) and (4) of section 110 [amending section 300e–9 of this title] shall apply with respect to failures of employers to comply with section 1310(a) of the Public Health Serv- ice Act [42 U.S.C. 300e–9(a)] after the date of the enact- ment of this Act [Oct. 8, 1976]. ‘‘(8) The amendment made by section 111 [amending section 300e–11 of this title] shall apply with respect to determinations of the Secretary of Health, Education, and Welfare described in section 1312(a) of the Public Health Service Act [42 U.S.C. 300e–11(a)] and made after the date of the enactment of this Act [Oct. 8, 1976].’’ SHORT TITLE OF 1978 AMENDMENT For short title of Pub. L. 95–559 as the ‘‘Health Main- tenance Organization Amendments of 1978’’, see section 1 of Pub. L. 95–559, set out as a note under section 201 of this title. SHORT TITLE OF 1976 AMENDMENT For short title of Pub. L. 94–460 which substantially amended this subchapter, as the ‘‘Health Maintenance Page 1214 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 300e–1 Organization Amendments of 1976’’, see section 1(a) of Pub. L. 94–460, set out as a note under section 201 of this title. SHORT TITLE For short title of Pub. L. 93–222, which enacted this subchapter, as the ‘‘Health Maintenance Organization Act of 1973’’, see section 1 of Pub. L. 93–222, set out as a Short Title of 1973 Amendments note under section 201 of this title. QUALIFICATION OF HEALTH MAINTENANCE ORGANIZATION CONTINGENT UPON CONTROLLING ORGANIZATION’S AS- SUMPTION OF FINANCIAL OBLIGATIONS AND MEETING OTHER REQUIREMENTS Pub. L. 100–517, § 5(a)(3), Oct. 24, 1988, 102 Stat. 2579, provided that: ‘‘During the period prior to the effective date of regulations issued under section 1301(c) of the Public Health Service Act [42 U.S.C. 300e(c)] (as amend- ed by paragraph (2)), the Secretary of Health and Human Services shall consider the application for qual- ification under section 1301(c)(1)(A) of such Act of a health maintenance organization— ‘‘(A) which is owned or controlled by another orga- nization, and ‘‘(B) which requests that the resources of the other organization be considered in determining its quali- fication under such section, if the Secretary receives satisfactory assurances from the other organization that it will assume the financial obligations of the health maintenance organization and if the Secretary determines that the other organization meets such other requirements as the Secretary deter- mines are necessary.’’ STUDY ON HEALTH MAINTENANCE ORGANIZATION PROGRAM Pub. L. 99–660, title VIII, § 813, Nov. 14, 1986, 100 Stat. 3801, which provided for a study to assess the operation and impact of the provisions of this subchapter and a report to Congress on the findings and conclusions of such study within 18 months after Nov. 14, 1986, was re- pealed by Pub. L. 102–531, title III, § 311(a), Oct. 27, 1992, 106 Stat. 3503, effective as if such repeal was enacted on Nov. 14, 1986. HEALTH CARE QUALITY ASSURANCE PROGRAMS STUDY Pub. L. 93–222, § 4, Dec. 29, 1973, 87 Stat. 934, required Secretary of Health, Education, and Welfare to con- tract for conduct of a study of health care quality as- surance programs and submit a final report to specific committees of Congress by Jan. 31, 1976. § 300e–1. Definitions 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 serv- ices; (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 an- cillary 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) infer- tility 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 nec- essary for the protection of individual health. The Secretary shall publish in the Federal Reg- ister 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 den- tist, optometrist, podiatrist, psychologist, or other health care personnel, a health mainte- nance organization may provide such service through a dentist, optometrist, podiatrist, psy- chologist, or other health care personnel (as the case may be) licensed to provide such service. Such term includes a health service directly as- sociated with an organ transplant only if such organ transplant was required to be included in basic health services on April 15, 1985. For pur- poses of this paragraph, the term ‘‘home health services’’ means health services provided at a member’s home by health care personnel, as pre- scribed or directed by the responsible physician or other authority designated by the health maintenance organization. (2) The term ‘‘supplemental health services’’ means any health service which is not included as a basic health service under paragraph (1) of this section. If a health service provided by a physician 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 an optometrist, dentist, podiatrist, psychologist, or other health care personnel (as the case may be) licensed to pro- vide such service. (3) The term ‘‘member’’ when used in connec- tion with a health maintenance organization means an individual who has entered into a con- tractual arrangement, or on whose behalf a con- tractual arrangement has been entered into, with the organization under which the organiza- tion assumes the responsibility for the provision to such individual of basic health services and of such supplemental health services as may be contracted for. (4) The term ‘‘medical group’’ means a part- nership, association, or other group— (A) which is composed of health profes- sionals licensed to practice medicine or oste- opathy and of such other licensed health pro- fessionals (including dentists, optometrists, podiatrists, and psychologists) as are nec- essary for the provision of health services for which the group is responsible; (B) a majority of the members of which are licensed to practice medicine or osteopathy; and (C) the members of which (i) as their prin- cipal professional activity engage in the co- ordinated practice of their profession and as a group responsibility have substantial responsi- bility for the delivery of health services to members of a health maintenance organiza- tion, except that this clause does not apply be- fore the end of the forty-eight month period