Page:United States Statutes at Large Volume 111 Part 1.djvu/521

 PUBLIC LAW 105-33—AUG. 5, 1997 111 STAT. 497 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. "(C) HEALTH CARE PROFESSIONAL DEFINED.— For purposes of this paragraph, the term 'health care professional' means a physician (as defined in section 186 l(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 SERV- ICES. — Each medicaid managed care organization shall provide the State and the Secretgiry 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 LL\BILITY FOR PAY- MENT.— 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 arrsingement with the organization in excess of the amount that would

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