vision of health care services in such a system) as the Secretary shall prescribe in regulations. (4) (A) An application for a grant or contract under section 300d-2 or 300d-3 of this title may not be approved by the Secretary unless (i) the application meets the requirements of subparagraphs (B) through (F) of paragraph (3), and (ii) except as provided in subparagraph (B) (ii), the applicant (I) demonstrates to the satisfaction of the Secretary that the emergency medical services system for which the application is submitted will, within the period specified in subparagraph (B) (i), meet each of the emergency medical services system requirements specified in subparagraph (C), and (II) provides in the application a plan satisfactory to the Secretary for the system to meet each such requirement within such period.

(B) (i) The period within which an emergency medical services system must meet each of the requirements specified in subparagraph (A) is the period of the grant or contract for which application is made; except that if the applicant demonstrates to the satisfaction of the Secretary the inability of the applicant's emergency medical services system to meet one or more of such requirements within such period, the period (or periods) within which the system must meet such requirement (or requirements) is such period (or periods) as the Secretary may require.

(ii) If an applicant submits an application for a grant or contract under section 300d-2 or 300d-3 of this title and demonstrates to the satisfaction of the Secretary the inability of the system for which the application is submitted to meet one or more of the requirements specified in subparagraph (C) within any specific period of time, the demonstration and plan prerequisites prescribed by clause (ii) of subparagraph (A) shall not apply with respect to such requirement (or requirements) and the applicant shall provide in his application a plan, satisfactory to the Secretary, for achieving appropriate alternatives to such requirement (or requirements). (C) An emergency medical services system shall

(i) include an adequate number of health professions, allied health professions, and other health personnel with appropriate training and experience;

(ii) provide for its personnel appropriate training (including clinical training) and continuing education programs which (I) are coordinated with other programs in the system's service area which provide similar training and education, and (II) emphasize recruitment and necessary training of veterans of the Armed Forces with military training and experience in health care fields and of appropriate public safety personnel in such area;

(iii) join the personnel, facilities, and equipment of the system by a central communications system so that requests for emergency health care services will be handled by a communications facility which (I) utilizes emergency medical telephonic screening, (II) utilizes or, within such period as the Secretary prescribes will utilize, the universal emergency telephone number 911, and (III) will have direct communication connections

and interconnections with the personnel, facilities, and equipment of the system and with other appropriate emergency medical services systems;

(iv) include an adequate number of necessary ground, air, and water vehicles and other transportation facilities to meet the individual characteristics of the system's service area

(I) which vehicles and facilities meet appropriate standards relating to location, design, performance, and equipment, and

(II) the operators and other personnel for which vehicles and facilities meet appropriate training and experience requirements;

(v) include an adequate number of easily accessible emergency medical services facilities which are collectively capable for providing services on a continuous basis, which have appropriate nonduplicative and categorized capabilities, which meet appropriate standards relating to capacity, location, personnel, and equipment, and which are coordinated with other health care facilities of the system;

(vi) provide access (including appropriate transportation) to specialized critical medical care units in the system's service area, or, if there are no such units or an inadequate number of them in such area, provide access to such units in neighboring areas if access to such units is feasible in terms of time and distance;

(vii) provide for the effective utilization of the appropriate personnel, facilities, and equipment of each public safety agency providing emergency services in the system's service area;

(viii) be organized in a manner that provides persons who reside in the system's service area and who have no professional training or financial interest in the provision of health care with an adequate opportunity to participate in the making of policy for the system;

(ix) provide, without prior inquiry as to ability to pay, necessary emergency medical services to all patients requiring such services;

(x) provide for transfer of patients to facilities and programs which offer such followup care and rehabilitation as is necessary to effect the maximum recovery of the patient;

(xi) provide for a standardized patient recordkeeping system meeting appropriate standards established by the Secretary, which records shall cover the treatment of the patient from initial entry into the system through his discharge from it, and shall be consistent with ensuing patient records used in followup care and rehabilitation of the patient;

(xii) provide programs of public education and information in the system's service area (taking into account the needs of visitors to, as well as residents of, that area to know or be able to learn immediately the means of obtaining emergency medical services) which programs stress the general dissemination of information regarding appropriate methods of medical self-help and firstaid and regarding the availability of first-aid training programs in the area;

(xiii) to provide for (I) periodic, comprehensive, and independent review and evaluation of the ex

tent and quality of the emergency health care services provided in the system's service area, and (II) submission to the Secretary of the reports of each such review and evaluation;

(xiv) have a plan to assure that the system will be capable of providing emergency medical services in the system's service area during mass casualties, natural disasters, or national emergencies; and

(xv) provide for the establishment of appropriate arrangements with emergency medical services systems or similiar entities serving neighboring areas for the provision of emergency medical services on a reciprocal basis where access to such services would be more appropriate and effective in terms of the services available, time, and distance.

The Secretary shall by regulations prescribe standards and criteria for the requirements prescribed by this subparagraph. In prescribing such standards and criteria, the Secretary shall consider relevant standards and criteria prescribed by other public agencies and by private organizations.

(5) The Secretary shall provide technical assistance, as appropriate, to eligible entities as necessary for the purpose of their preparing applications or otherwise qualifying for or carrying out grants or contracts under sections 300d-1, 300d-2, or 300d-3 of this title, with special consideration for applicants in rural areas.

(c) Payments; advances or reimbursement; installments; conditions.

Payments under grants and contracts under this subchapter may be made in advance or by way of reimbursement and in such installments and on such conditions as the Secretary determines will most effectively carry out this subchapter.

(d) Prohibitions and restrictions inapplicable.

Contracts may be entered into under this subchapter without regard to section 529 of Title 31 and section 5 of Title 41.

(e) New grants or contracts; use of funds; definition. No funds appropriated under any provision of this chapter other than section 300d-6 of this title or subchapter V of this chapter may be used to make a new grant or contract in any fiscal year for a purpose for which a grant or contract is authorized by this subchapter unless (1) all the funds authorized to be appropriated by section 300d-6 of this title for such fiscal year, have been appropriated and made available for obligation in such fiscal year, and (2) such new grant or contract is made in accordance with the requirements of this subchapter that would be applicable to such grant or contract if it was made under this subchapter. For purposes of this subsection, the term "new grant or contract" means a grant or contract for a program or project for which an application was first submitted after the date of the enactment of the Act which makes the first appropriations under the authorizations contained in section 300d-6 of this title.

(f) Amount of grant or contract; considerations; 'conditions for use of funds.

(1) In determining the amount of any grant or contract under section 300d-2 or 300d-3 of this title,

the Secretary shall take into consideration the amount of funds available to the applicant from Federal grant or contract programs under laws other than this chapter for any activity which the applicant proposes to undertake in connection with the establishment and operation or expansion and improvement of an emergency medical services system and for which the Secretary may authorize the use of funds under a grant or contract under sections 300d-2 and 300d-3 of this title.

(2) The Secretary may not authorize the recipient of a grant or contract under section 300d-2 or 300d-3 of this title to use funds under such grant or contract for any training program in connection with an emergency medical services system unless the applicant filed an application (as appropriate) under subchapter V or VI of this chapter for a grant or contract for such program and such application was not approved or was approved but for which no or inadequate funds were made available under such subchapter. (July 1, 1944, ch. 373, title XII, § 1206, as added Nov. 16, 1973, Pub. L. 93-154, § 2(a), 87 Stat. 598.)

CROSS REFERENCES

Section 314(a) State health planning agency, section 314(b) areawide health planning agency, and section 314 (b) plan defined, see section 300d of this title.

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 300d-1 to 300d-3 of this title.

§ 300d-6. Authorization of appropriations.

(a) (1) For the purpose of making payments pursuant to grants and contracts under sections 300d-1, 300d-2, and 300d-3 of this title, there are authorized to be appropriated $30,000,000 for the fiscal year ending June 30, 1974, and $60,000,000 for the fiscal year ending June 30, 1975; and for the purpose of making payments pursuant to grants and contracts under sections 300d-2 and 300d-3 of this title for the fiscal year ending June 30, 1976, there are authorized to be appropriated $70,000,000.

(2) Of the sums appropriated under paragraph (1) for any fiscal year, not less than 20 per centum shall be made available for grants and contracts under this subchapter for such fiscal year for emergency medical services systems which serve or will serve rural areas (as defined in regulations of the Secretary under section 300d-2 (c) (5) of this title).

(3) Of the sums appropriated under paragraph (1) for the fiscal year ending June 30, 1974, or the succeeding fiscal year

(A) 15 per centum of such sums for each such fiscal year shall be made available only for grants and contracts under section 300d-1 of this title (relating to feasibility studies and planning) for such fiscal year;

(B) 60 per centum of such sums for each such fiscal year shall be made available only for grants and contracts under section 300d-2 of this title (relating to establishment and initial operation) for such fiscal year; and

(C) 25 per centum of such sums for each such fiscal year shall be made available only for grants and contracts under section 300d-3 of this title (relating to expansion and improvement) for such fiscal year.

(4) Of the sums appropriated under paragraph (1) for the fiscal year ending June 30, 1976—

(A) 75 per centum of such sums shall be made available only for grants and contracts under section 300d-2 of this title for such fiscal year, and (B) 25 per centum of such sums shall be made available only for grants and contracts under section 300d-3 of this title for such fiscal year.

(b) For the purpose of making payments pursuant to grants and contracts under section 300d-4 of this title (relating to research), there are authorized to be appropriated $5,000,000 for the fiscal year ending June 30, 1974, and for each of the next two fiscal years. (July 1, 1944, ch. 373, title XII, § 1207, as added Nov. 16, 1973, Pub. L. 93–154, § 2(a), 87 Stat. 602.)

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in section 300d-5 of this title.

§ 300d-7. Administration.

The Secretary shall administer the program of grants and contracts authorized by this subchapter through an identifiable administrative unit within the Department of Health, Education, and Welfare. Such unit shall also be responsible for collecting, analyzing, cataloging, and disseminating all data useful in the development and operation of emergency medical services systems, including data derived from reviews and evaluations of emergency medical services systems assisted under section 300d2 or 300d-3 of this title. (July 1, 1944, ch. 373, title XII, § 1208, as added Nov. 16, 1973, Pub. L. 93-154, § 2(a), 87 Stat. 602.)

§ 300d-8. Interagency Committee on Emergency Medical Services.

(a) Establishment; functions.

The Secretary shall establish an Interagency Committee on Emergency Medical Services. The Committee shall evaluate the adequacy and technical soundness of all Federal programs and activities which relate to emergency medical services and provide for the communication and exchange of information necessary to maintain the coordination and effectiveness of such programs and activities, and shall make recommendations to the Secretary respecting the administration of the program of grants and contracts under this subchapter (including the making of regulations for such program).

(b) Chairman of Committee; membership representative of Federal agencies and offices and general public; meetings.

The Secretary or his designee shall serve as Chairman of the Committee, the membership of which shall include (1) appropriate scientific, medical, or technical representation from the Department of Transportation, the Department of Justice, the Department of Defense, the Veterans' Administration, the National Science Foundation, the Federal Communications Commission, the National Academy of Sciences, and such other Federal agencies and offices (including appropriate agencies and offices of the Department of Health, Education, and Welfare), as the Secretary determines administer programs directly affecting the functions or responsibilities of emergency medical services systems, and (2) five individuals from the general public appointed by the

President from individuals who by virtue of their training or experience are particularly qualified to participate in the performance of the Committee's functions. The Committee shall meet at the call of the Chairman, but not less often than four times a year.

(c) Term of office; vacancies; service after expiration of term.

Each appointed member of the Committee shall be appointed for a term of four years, except that—

(1) any member appointed to fill a vacancy occurring prior to the expiration of the term for which his predecessor was appointed shall be appointed for the remainder of such term; and

(2) of the members first appointed, two shall be appointed for a term of four years, two shall be appointed for a term of three years, and one shall be appointed for a term of one year, as designated by the President at the time of appointment. Appointed members may serve after the expiration of their terms until their successors have taken office. (d) Compensation and travel expenses.

Appointed members of the Committee shall receive for each day they are engaged in the performance of the functions of the Committee compensation at rates not to exceed the daily equivalent of the annual rate in effect for grade GS-18 of the General Schedule, including traveltime; and all members, while so serving away from their homes or regular places of business, may be allowed travel expenses, including per diem in lieu of subsistence, in the same manner as such expenses are authorized by section 5703 of Title 5 for persons in the Government service employed intermittently.

(e) Staff, information, and other assistance.

The Secretary shall make available to the Committee such staff, information (including copies of reports of reviews and evaluations of emergency medical services systems assisted under section 300d-2 or 300d-3 of this title), and other assistance as it may require to carry out its activities effectively. (July 1, 1944, ch. 373, title XII, § 1209, as added Nov. 16, 1973, Pub. L. 93-154, § 2(a), 87 Stat. 602.) REFERENCES IN TEXT

The General Schedule, referred to in subsec. (d), is set out under section 5332 of Title 5, Government Organization and Employees.

§ 300d-9. Annual report to Congress.

The Secretary shall prepare and submit annually to the Congress a report on the administration of this subchapter. Each report shall include an evaluation of the adequacy of the provision of emergency medical services in the United States during the period covered by the report, and evaluation of the extent to which the needs for such services are being adequately met through assistance provided under this subchapter, and his recommendations for such legislation as he determines is required to provide emergency medical services at a level adequate to meet such needs. The first report under this section shall be submitted not later than September 30, 1974, and shall cover the fiscal year ending June 30, 1974. (July 1, 1944, ch. 373, title XII, § 1210, as added Nov. 16, 1973, Pub. L. 93–154, § 2(a), 87 Stat. 603.)

SUBCHAPTER XI.-HEALTH MAINTENANCE

ORGANIZATIONS [New]

SECTION REFERRED TO IN OTHER SECTIONS This subchapter is referred to in title 12 section 1721.

§ 300e. Requirements of health maintenance organizations.

(a) Definition of health maintenance organization.

For purposes of this subchapter, the term "health maintenance organization" means a legal entity which (1) provides basic and supplemental health services to its members in the manner prescribed by subsection (b) of this section, and (2) is organized and operated in the manner prescribed by subsection (c) of this section.

(b) Manner of supplying basic and supplemental health services to members.

A health maintenance organization shall provide, without limitations as to time or cost other than those prescribed by or under this subchapter, 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 subchapter 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 provide to each of its members each health service (A) which is included in supplemental health services (as defined in section 300e-1 (2) of this title), (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 staff of the health maintenance organization, or through a medical group (or groups) 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 professionals" means physicians, dentists, nurses, podiatrists, 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.

(c) Organization, practices, and activities. Each health maintenance organization shall

(1) have a fiscally sound operation and adequate provision against the risk of insolvency which is satisfactory to the Secretary;

(2) assume full financial risk on a prospective basis for the provision of basic health services, except that a health maintenance organization may obtain insurance or make other arrangements (A) for the cost of providing to any member basic health services the aggregate value of which exceeds $5,000 in any year, (B) for the cost of basic health services provided to its members other than through the organization because medical necessity required their provision before they could be secured through the organization, and (C) for not more than 90 per centum of the amount by which its costs for any of its fiscal years exceed 115 per centum of its income for such fiscal year;

(3) enroll persons who are broadly representative of the various age, social, and income groups within the area it serves, except that in the case of a health maintenance organization which has a medically underserved population located (in whole or in part) in the area it serves, not more than 75 per centum of the members of that organization may be enrolled from the medically underserved population unless the area in which such population resides is also a rural area (as designated by the Secretary);

(4) have an open enrollment period of not less than thirty days at least once during each consecutive twelve-month period during which enrollment period it accepts, up to its capacity, individuals in the order in which they apply for enrollment, except that if the organization demonstrates to the satisfaction of the Secretary that

(A) it has enrolled, or will be compelled to enroll, a disproportionate number of individuals who are likely to utilize its services more often

20-347 0-74-vol. 234

than an actuarially determined average (as determined under regulations of the Secretary) and enrollment during an open enrollment period of an additional number of such individuals will jeopardize its economic viability, or

(B) if it maintained an open enrollment period it would not be able to comply with the requirements of paragraph (3),

the Secretary may waive compliance by the organization with the open enrollment requirement of this paragraph for not more than three consecutive twelve-month periods and may provide additional waivers to that organization if it makes the demonstration required by subparagraph (A) or (B);

(5) not expel or refuse to re-enroll any member because of his health status or his requirements for health services;

(6) be organized in such a manner that assures that (A) at least one-third of the membership of the policymaking body of the health maintenance organization will be members of the organization, and (B) there will be equitable representation on such body of members from medically underserved populations served by the organization;

(7) be organized in such a manner that provides meaningful procedures for hearing and resolving grievances between the health maintenance organization (including the medical group or groups and other health delivery entities providing health services for the organization) and the members of the organization;

(8) have organizational arrangements, established in accordance with regulations of the Secretary, for an ongoing quality assurance program for its health services which program (A) stresses health outcomes, and (B) provides review by physicians and other health professionals of the process followed in the provision of health services;

(9) provide medical social services for its members and encourage and actively provide for its members health education services, education in the appropriate use of health services, and education in the contribution each member can make to the maintenance of his own health;

(10) provide, or make arrangements for, continuing education for its health professional staff; and

(11) provide, in accordance with regulations of the Secretary (including safeguards concerning the confidentiality of the doctor-patient relationship), an effective procedure for developing, compiling, evaluating, and reporting to the Secretary, statistics and other information (which the Secretary shall publish and disseminate on an annual basis and which the health maintenance organization shall disclose, in a manner acceptable to the Secretary, to its members and the general public) relating to (A) the cost of its operations, (B) the patterns of utilization of its services, (C) the availability, accessibility, and acceptability of its services, (D) to the extent practical, developments in the health status of its members, and (E) such other matters as the Secretary may require. (July 1, 1944, ch. 373, title XIII, § 1301, as added Dec. 29, 1973, Pub. L. 93-222, § 2, 87 Stat. 914.)

SHORT TITLE

Section 1 of Pub. L. 93-222 provided in part that Pub. L. 93-222 [which enacted this subchapter and section 280c of this title, amended section 172 of Title 12, Bank and Banking, and sections 201 note and 2001 of this title, repealed section 763c of Title 33, Navigation and Navigable Waters, and sections 201 notes, 211a, 212a, and 222 notes of this section, and enacted provisions set out as notes under this section and section 300e-1 of this title] shall be cited as the "Health Maintenance Organization Act of 1973." HEALTH CARE QUALITY ASSURANCE PROGRAMS STUDY Section 4 of Pub. L. 93–222 provided that:

"(a) The Secretary of Health, Education, and Welfare shall contract, in accordance with subsection (b), for the conduct of a study to

"(1) analyze past and present mechanisms (both required by law and voluntary) to assure the quality of health care, identify the strengths and weaknesses of current major prototypes of health care quality assurance systems, and identify on a comparable basis the costs of such prototypes;

"(2) provide a set of basic principles to be followed by and effective health care quality assurance system, including principles affecting the scope of the system, methods for assessing care, data requirements, specifications for the development of criteria and standards which relate to desired outcomes of care, and means for assessing the responsiveness of such care to the needs and perceptions of the consumers of such care;

"(3) provide an assessment of programs for improving the performance of health practitioners and institutions in providing high-quality health care, including a study of the effectiveness of sanctions and educational programs;

"(4) define the specific needs for a program of research and evaluation in health care quality assurance methods, including the design of prospective evaluations protocols for health care quality assurance systems; and

"(5) provide methods for assessing the quality of health care from the point of view of consumers of such

care.

"(b) The Secretary shall contract for the conduct of the study required by subsection (a) with a nonprofit private organization which

"(1) has a national reputation for objectivity in the conduct of studies for the Federal Government;

"(2) has the capacity to readily marshall the widest possible range of expertise and advice relevant to the conduct of such study;

"(3) has a membership and competent staff which have backgrounds in government, the health sciences, and the social sciences;

"(4) has a history of interest and activity in health policy issues related to such study; and

"(5) has extensive existing contracts with interested public and private agencies and organizations. The Secretary shall enter into such contract within 90 days of the date of the enactment of the first Act making an appropriation under subsection (d).

"(c) An interim report providing a plan for the study required by subsection (a) shall be submitted by the organization conducting the study to the Committee on Interstate and Foreign Commerce of the House of Representatives and the Committee on Labor and Public Welfare of the Senate by June 30, 1974; and a final report giving the results of the study and providing specifications for an effective quality assurance system shall be submitted by such organization to the Committee on Interstate and Foreign Commerce of the House of Representatives and the Committee on Labor and Public Welfare of the Senate by January 31, 1976.

"(d) There is authorized to be appropriated $10,000,000, which shall be available without fiscal year limitation, for the conduct of the study required by subsection (a)."

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 300e-5, 300e-6, 300e-9 to 300e-11, 300e-13, 300e-14 of this title.