Page:United States Statutes at Large Volume 87.djvu/947

 87 STAT. ]

PUBLIC LAW 93-222-DEC. 29, 1973

915

a c '•(b) A health maintenance organization shall provide, without s eBv isci e s.health r limitations as to time or cost other than those prescribed by or under this title, 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 payment which (A) is to be paid on a periodic basis without regard to the dates health services (within the basic health services) are provided; (B) is fixed without regard to the frequency, extent, or kind of health service (within the basic health services) actually furnished; (C) is fixed under a community rating system; and (D) may be supplemented by additional nominal 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 manner that they serve (as determined under regulations of the Secretary) as a barrier to the delivery of health services. Such additional nominal payments shall be fixed in accordance with the regulations of the Secretary. "(2) For such payment or payments (hereinafter in this title referred to as 'supplemental health services payments') as the health maintenance organization may require in addition to the basic health services payment, the organization shall pro\'ide to each of its member's each health service (A) which is included in supplemental health services (as defined in section 1302(2)), (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 organization. Supplemental health services payments which are fixed on a prepayment basis shall be fixed under a community rating system. " (3) The services of health professionals which are provided as basic health services shall be provided through health professionals who are members of the stafi^ of the health maintenance organization or through a medical group (or gr-oups) or individual practice association (or associations), except that this paragraph shall not apply in the case of (A) health professionals* services which the organization determines, in conformity with regulations of the Secretary, are unusual or infrequently used, or (B) any basic health service provided a member of the health maintenance organization other than by such a health professional because it was medically necessary that the service be provided to the member before he could have it provided by such a health professional. For purposes of this paragraph, the term '"health ^ "Health pro professionals' means physicians, dentists, nurses, podiatrists, f e s s i o n a l s. optometrists, and such other individuals engaged in the delivery of health services as the Secretary may by regulation designate. "'(4) Basic health services (and supplemental health services in the case of the members who have contracted therefor) shall within the area served by the health maintenance organization be available and accessible to each of its members promptly as appropriate 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. A member of a health maintenance organization shall be reimbursed by the organization for his expenses in securing basic or supplemental health services other than through the organization if it was medically necessary that the services be provided before he could secure them through the organization.

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