2 (2) the present health care system is not organized in a manner which encourages the efficient and eco nomical provision of quality health care; (3) the present health care system is oriented toward providing care to those manifesting disease, rather than toward providing health maintenance services and maintaining good health; (4) the establishment of health maintenance organizations, health service organizations, and area health education and service centers will aid in alleviating the maldistribution of health care resources, in providing health care in a more efficient and economical manner, and in reorienting the health care system toward the maintenance of health; (5) there is a need to provide technical assistance and resources to individuals and groups, undertaking the planning, development, and initial operation of health maintenance organizations, health service organizations, and area health education and service centers; (6) there is a shortage of educational facilities in health sciences, unbalanced emphasis on hospital practice and on rare and exotic diseases in medical education; and (7) there exists an excessive variance in the qual ity of health care and health services. (b) The purpose of this Act is to assist in improving 3 1 the system for the delivery of health care through encourage2 ment of and support for the planning, development, and 3 initial operation of health maintenance organizations, health 4 service organizations, and area health education and service 5 centers, particularly with the intent of improving the health 6 of populations in medically underserved areas. 7 8 TITLE I-HEALTH MAINTENANCE ORGANIZATIONS 9 SEC. 101. The Public Health Service Act is amended by 10 inserting after title X the following new title: 11 "TITLE XI-HEALTH MAINTENANCE ORGANIZA 18 "(1) The term 'health maintenance organization' 19 means an entity which 20 "(A) provides as a minimum for all its enrollees 21 (or subscribers) comprehensive health services (as de 225 23 24 25 fined in this section) which are uniformly available to all its enrollees (or subscribers) directly through its own staff and supporting resources or through a medical group or groups and such other additional services as 4 1 2 3 4 7 8 may be required through other health delivery entities, for a fixed payment which (i) is to be paid on a periodic basis without regard to the frequency, extent, or kind of health service actually furnished to any particular enrollee; and (ii) is uniform for all its enrollees; "(B) demonstrates to the satisfaction of the Sec retary ability to assure that appropriate comprehensive health services are available and accessible to all its 9 enrollees promptly and in a manner which assures continuity; "(C) demonstrates to the satisfaction of the Secretary financial responsibility through proof of adequate provision against the risk of insolvency; "(D) is organized in such a manner (as prescribed by regulations of the Secretary) that assures its members a substantial role in the making of policy for the health maintenance organization, with equitable representation of members from medically underserved areas, and provides meaningful procedures for hearing and resolving grievances (i) between its enrollees and the health maintenance organization (including the medical group or groups and other health delivery entities providing health services) and (ii) between the medical group or groups providing health services and other employees and the health maintenance organization; 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 5 "(E) encourages and actively provides for its enrollees (i) health education services, and (ii) education in the appropriate use of health services provided; "(F) has organizational arrangements, established in accordance with regulations of the Commission on Quality Health Care (established under title IV of this stresses health outcomes and assures that health services provided meet the quality standards established in ac cordance with regulations of the Commission on Quality Health Care; "(G) provides, in accordance with regulations of the Secretary (including safeguards concerning the confidentiality of the doctor-patient relationship), an effec tive procedure for developing, compiling, evaluating, and reporting to the Secretary, data (which the Secre tary shall publish and disseminate on an annual basis) relating to (i) the cost of its operations, (ii) the pat terns of utilization of its services, (iii) the availability, accessibility, and acceptability of its services, and (iv) such other matters as the Secretary may require and disclose at least annually and in a manner acceptable to the Secretary, such data to its enrollees and to the gen eral public; "(H) except for (i) out of area emergency care, 6 and (ii) care reasonably valued in excess of the first $5,000 per member per year, assumes full financial re sponsibility, without benefit of insurance, on a prospec tive basis for the provision of the comprehensive health services defined in this section; "(I) subject to the requirements of paragraph (K), has an open enrollment period (of not less than thirty days) at least once during each consecutive twelvemonth period during which it accepts individuals in the order in which they apply for enrollment up to its capac ity as determined by the Secretary; "(J) assumes responsibility for the provision of health care services to its enrollees twenty-four hours a day, seven days a week, as may be appropriate and for the prompt availability of such services in emergencies; "(K) shall enroll no more than 50 per centum of its members from medically underserved areas, except in rural areas as designated by the Secretary; "(L) provides, or makes arrangements for continu ing education for its staff; "(M) emphasizes the use of physician's assistants, dental therapists, nurse practitioners, and other allied health personnel; "(N) meets such other criteria for its organization |