Health Maintenance Organization Amendments of 1976

(Conference report filed in House, H. Rept. 94-1513)

Health Maintenance Organization Amendments - =Title I: Amendments to Title XIII of the Public Health Service Act= - Expands the program of health maintenance organizations by: (1) including the services of professional personnel and allied health professions personnel for the effective and efficient delivery of the basic health services; (2) authorizing them to provide basic health services through medical groups, referral services and medical treatment for abuse of or addiction to alcohol or drugs and supplemental health services; and (3) guaranteeing to non-Federal lenders payment of principal and interest on loans made to establish or expand health maintenance organizations or to serve medically underserved populations. Provides that in any fiscal year the amount disbursed to a health maintenance organization under this Act shall not exceed $1,000,000.

Requires employers of not less than 25 individuals to offer as a part of any health benefits plan the option of membership in qualified health maintenance organizations which a are engaged in the provision of basic health services.

Provides that the substantial responsibility of the members of the medical group of the HMO should be the delivery of medical services to the HMO enrollees. Requires members of the medical group to pool their income and distribute it according to a plan that is not related to the provision of specific health services.

Provides that an enrollee's status in the HMO not be known by the health professional at the time of provision of services.

Permits Individual Practice Associations (IPAs) to qualify as HMOs.

Provides that HMOs which have been in existence for five years or have an enrollment of 50,000 members and have not incurred a deficit in the most recent fiscal year shall have open enrollment periods of at least 30 days not less than once a year in which they accept persons in order of application regardless of existing illness, medical condition, or degree of disability. Exempts such HMOs from enrolling persons confined to institutions because of chronic illness, permanent injury, or other infirmity.

Provides for a four-year waiver of the requirement for community rating of payments for health services and supplemental health services from HMOs.

Permits nonprofit private HMOs to obtain Federal loan guarantees for planning, initial development, and initial operation. Gives priority in such guarantees to HMO applicants proposing to serve medically underserved populations. Increases from $50,000 to $75,000 the amount of a grant or contract for a feasibility survey and from $125,000 to $200,000 the amount for and single planning project relating to HMOs.

Extends the number of years of Federal assistance for initial operation of HMOs from three to five years.

Authorizes the Secretary of Health, Education, and Welfare, in order to enforce compliance with assurances made by health maintenance organizations respecting the provision of basic and supplemental health services, to bring a civil action in Federal court.

States that employers required to afford such an option shall not include the Government of the United States, the government of the District of Columbia or any territory or possession of the United States, any agency or instrumentality (including the United States Postal Service and Postal Rate Commission) of any of the foregoing, or church-related organizations.

Requires the Civil Service Commission to contract with any health carrier which is a qualified health maintenance organization approved by the Secretary of Health, Education, and Welfare, and which offers a health benefits plan that meets the statutory standards for health benefits plans.

Makes specified appropriations to finance the activities of health maintenance organizations for fiscal years 1977 and 1978.

=Title II: Amendments to the Social Security Act= - Makes the definition of an HMO and the requirements thereof under title XVIII (Medicare) of the Social Security Act the same as those under the Public Health Service Act. Authorizes the Assistant Secretary of Health of the Department of Health, Education, and Welfare to determine whether an organization is an HMO under the Social Security Act. Requires, under such Act, that such HMOs have at least half of their members under age 65. Requires an annual open enrollment in such HMOs for Medicare beneficiaries.

Makes the requirements for an HMO under title XIX (Medicaid) of the Social Security Act the same as those under the Public Health Service Act. Prohibits payments to States for expenditures incurred by contracting with an entity which provides comprehensive services, hospital care and one other service, or any three services, which has not been determined to be an HMO on other than an cost basis, or which has received grants as a community health or migrant health center.

Establishes a Health Services Policy Analysis Center for additional health services research.

Authorizes appropriations through September 20, 1977, for home health extension.