Page:United States Statutes at Large Volume 111 Part 1.djvu/516

 Ill STAT. 492 PUBLIC LAW 105-33 —AUG. 5, 1997 " (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 SERV- ICES. —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 title, inform the enrollee in a written and prominent manner of any benefits to which the enrollee may be entitled to under this title 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) CHANGE IN TERMINOLOGY.— (1) IN GENERAL.— Section 1903(m)(l)(A) (42 U.S.C. 1396b(m)) is amended— (A) by striking 'The term" and all that follows through "and—" and inserting "The term 'medicaid managed care organization' means a health maintenance organization, an eligible organization with a contract under section 1876 or a Medicare+Choice organization with a contract under part C of title XVIII, a provider sponsored organization,

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