Page:United States Statutes at Large Volume 92 Part 2.djvu/858

 92 STAT. 2138

PUBLIC LAW 95-559—NOV. 1, 1978 REQUIREMENTS FOR THE PROVISION OF SERVICES

42 USC 300e.

42 USC 300e-l.

Contracts with other than staff physicians, prohibition.

SEC. 11. (a) Paragraph (3) of section 1310(b) is amended to read as follows: "(3)(A) Except as provided in subparagraph (B), the services of a physician vs^hich are provided as basic health services 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) subject to subparagraph (C), physicians or other health professionals 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 association (or associations) or physicians or other health professionals under contract with the organization. "(B)(i) Subparagraph (A) does not apply to the provision of the services of a physician— " (I) which the health maintenance organization determines, in conformity with regulations of the Secretary, are unusual or infrequently used, or " ( II) which are provided a member of the organization in a manner other than that prescribed by subparagraph (A) because of an emergency which made it medically necessary that the service be provided to the member before it could be provided in a manner prescribed by subparagraph (A), "(ii) In a forty-eight-month period beginning after the month in which a health maintenance organization becomes a qualified health maintenance organization (within the meaning of section 1310(d)), the organization may provide the services of physicians through an entity which but for the requirement of section 1302 (4)(C)(i) would be a medical group for the purposes of this title. After the expiration of such period, the organization may provide physician services through such an entity only if authorized by the Secretary in accordance with regulations which take into consideration the unusual circumstances of such entity. "(C) After the expiration of the first four fiscal years of a health maintenance organization beginning after the month in which it became a qualified health maintenance organization (within the meaning of section 1310(d)), the organization may not enter into contracts with physicians other than members of staff, medical groups, or individual practice associations if the amounts paid under such contracts for basic and supplemental health services provided by physicians exceed 15 per centum of the total estimated amount to be paid in such fiscal year by the health maintenance organization to physicians for the provision of basic and supplemental health services by physicians, or, if the health maintenance organization principally serves a rural area, 30 per centum of such amount, except that this subparagraph does not apply to the entering into contracts for the purchase of physician services through an entity which, but for the requirements of

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