Page:United States Statutes at Large Volume 96 Part 1.djvu/387

 PUBLIC LAW 97-248-SEPT. 3, 1982

96 STAT. 345

because of the individual's health status or requirements for health care services, and that it will notify each such individual of such fact at the time of the individual's enrollment. "(4) The organization must— "(A) make the services described in paragraph (2) (and such other health care services as such individuals have contracted for)(i) available and accessible to each such individual, within the area served by the organization, promptly as appropriate and in a manner which assures continuity, and (ii) when medically necessary, available and accessible twenty-four hours a day and seven days a week, and (B) provide for reimbursement with respect to services which are described in subparagraph (A) and which are provided to such an individual other than through the organization, if (i) the services were medically necessary and immediately required because of an unforeseen illness, injury, or condition and (ii) it was not reasonable given the circumstances to obtain the services through the organization. "(5)(A) The organization must provide meaningful procedures for hearing and resolving grievances between the organization (including any entity or individual through which the organization provides health care services) and members enrolled with the organization under this section. "(B) A member enrolled with an eligible organization under this section who is dissatisfied by reason of his failure to receive any health service to which he believes he is entitled and at no greater charge than he believes he is required to pay is entitled, if the amount in controversy is $100 or more, to a hearing before the Secretary to the same extent as is provided in section 205(b), and in 42 USC 405. any such hearing the Secretary shall make the eligible organization a party. If the amount in controversy is $1,000 or more, the individual or eligible organization shall, upon notifying the other party, be entitled to judicial review of the Secretary s final decision as provided in section 205(g), and both the individual and the eligible organization shall be entitled to be parties to that judicial review. "(6) The organization must have arrangements, established in accordance with regulations of the Secretary, for an ongoing quality assurance program for health care services it provides to such individuals, which program (A) stresses health outcomes and (B) provides review by physicians and other health care professionals of the process followed in the provision of such health care services. "(d) Subject to the provisions of subsection (c)(3), every individual entitled to benefits under part A and enrolled under part B or 42 USC 1395c, enrolled under part B only (other than an individual medically 1395j. determined to have end-stage renal disease) shall be eligible to enroll under this section with any eligible organization with which the Secretary has entered into a contract under this section and which serves the geographic area in which the individual resides. "(e)(1) In no case may— "(A) the portion of an eligible organization's premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with respect to services covered under parts A and B) to individuals who are enrolled under this section with the organization and who are entitled to benefits under part A and enrolled under part B, or "(B) the portion of its premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with

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