Page:United States Statutes at Large Volume 96 Part 1.djvu/385

 PUBLIC LAW 97-248—SEPT. 3, 1982 zation shall be entitled to receive payments from the Secretary under this title for services furnished to the individual. "(b) For purposes of this section, the term 'eligible organization' means a public or private entity (which may be a health maintenance organization or a competitive medical plan), organized under the laws of any State, which— "(1) is a qualified health maintenance organization (as defined in section 1310(d) of the Public Health Service Act), or "(2) meets the following requirements: "(A) The entity provides to enrolled members at least the following health care services: "(i) Physicians' services performed by physicians (as defined in section 1861(r)(l)). "(ii) Inpatient hospital services, "(iii) Laboratory, X-ray, emergency, and preventive services. "(iv) Out-of-area coverage. "(B) The entity is compensated (except for deductibles, coinsurance, and copayments) for the provision of health care services to enrolled members by a payment which is paid on a periodic basis without regard to the date the health care services are provided and which is fixed without regard to the frequency, extent, or kind of health care service actually provided to a member. "(C) The entity provides physicians' services primarily (i) directly through physicians who are either employees or partners of such organization, or (ii) through contracts with individual physicians or one or more groups of physicians (organized on a group practice or individual practice basis). "(D) The entity assumes full financial risk on a prospective basis for the provision of the health care services listed in paragraph (1), except that such entity may— "(i) obtain insurance or make other arrangements for the cost of providing to any enrolled member health care services listed in subparagraph (A) the aggregate value of which exceeds $5,000 in any year, "(ii) obtain insurance or make other arrangements for the cost of health care service listed in subparagraph (A) provided to its enrolled members other than through the entity because medical necessity required their provision before they could be secured through the entity, "(iii) obtain insurance or make other arrangements for not more than 90 percent of the amount by which its costs for any of its fiscal years exceed 115 percent of its income for such fiscal year, and "(iv) make arrangements with physicians or other health professionals, health care institutions, or any combination of such individuals or institutions to assume all or part of the financial risk on a prospective basis for the provision of basic health services by the physicians or other health professionals or through the institutions. "(E) The entity has made adequate provision against the risk of insolvency, which provision is satisfactory to the Secretary.

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l.S: OL3

96 STAT. 343

"Eligible organization."

42 USC 300e-9.

42 USC 1395x.

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