Page:United States Statutes at Large Volume 86.djvu/1442

 1400

PUBLIC LAW 92-603-OCT. 30, 1972

[86 STAT.

per capita basis, regardless of whether the individual physician members of any such group are paid on a fee-for-service or other basis; "(4) provides either directly or under arrangements with others, the services of a sufficient number of primary care and specialty care physicians to meet the health needs of its members; by«?ria^n"»^ "^'^ ^^^" P^rposes of this section the term 'specialty care physician' physician. means a physician who is either board certified or eligible for board certification, except that the Secretary may by regulation prescribe conditions under which physicians who have a record ., of demonstrated proficiency but who are not eligible for board certification may, on the basis of training and experience, be recognized as specialty care physicians; " (5) has effective arrangements to assure that its members have access to qualified practitioners in those specialties which are generally available in the geographic area served by the health maintenance organization; "(6) demonstrates to the satisfaction of the Secretary proof of financial responsibility and proof of capability to provide comprehensive health care services, including institutional services, efficiently, effectively, and economically; "(7) except as provided in subsection (h), has at least half of its enrolled members consisting of individuals under age 65; "(8) assures that the health services required by its members are received promptly and appropriately and that the services that are received measure up to quality standards which it establishes in accordance with regulations; and "(9) has an open enrollment period at least every year under ,,. which it accepts up to the limits of its capacity and without restrictions, except as may be authorized in regulations, individuals who are eligible to enroll under subsection (d) in the order in which they apply for enrollment (unless to do so would result in failure to meet the requirements of paragraph (7)) or would ,. result in enrollment of enrollees substantially nonrepresentative, as determined in accordance with regulations of the Secretary, of the population in the geographic area served by such health maintenance organization. "(c) The benefits provided under this section to enrollees of an organization which has entered into a risk sharing contract with the Post, p. 1401. Secretary pursuant to subsection (i)(2)(A) shall consist of— "(1) in the case of an individual who is entitled to hospital 42 USC 1395c. insurance benefits under part A and enrolled for medical insur42 USC 1395J. ance benefits under part B— " (A) entitlement to have payment made on his behalf for 79 ^*g'-^^-^all services described in section 1812 and section 1832 which Post, p. 1406. are furnished to him by the health maintenance organization with which he is enrolled pursuant to subsection (e) of this section; and " (B) entitlement to have payment made by such health maintenance organization to him or on his behalf for (i) such emergency services (as defined in regulations.), (ii) such urgently needed services (as defined in regulations) furnished to him during a period of temporary absence (as defined in regulations) from the geographic area served by the health maintenance organization with which he is enrolled, and (iii) such other services as may be determined, in accordance with subsection (f), to be services which the individual was entitled to have furnished by the health

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