Health Maintenance Organization Amendments

(Reported to House from the Committee on Interstate and Foreign Commerce with amendment, H. Rept. 95-1479)

Health Maintenance Organization Amendments - Extends the authorization of appropriations under the Public Health Service Act through fiscal year 1981 for: (1) grants and contracts for surveys of the feasibility of establishing, operating, or expanding health maintenance organizations (HMOs) and (2) grants, contracts, loans and guarantees for planning and initial development costs related to the establishment of HMOs.

Permits HMOs to seek reimbursement for the cost of services provided to a member who is entitled to benefits under a workmen's compensation law or an insurance policy.

Allows HMOs up to five years to reduce their reliance on contracts with physicians other than staff physicians or those who are not into medical groups or individual practice associations. Limits the amounts paid for the services of such physicians to 50 percent at any time and 15 percent (30 percent in rural areas) in the fifth and succeeding years.

Removes the financial responsibility of HMOs for services provided by another organization to HMO members who intentionally left the HMO service area to secure such services.

Provides that HMOs are only required to make good faith efforts to provide health services in the event that disaster, war, or other occurrences beyond their control prevent service in accordance with this Act.

Excludes from the definition of basic health services, any health service which the Secretary of Health, Education, and Welfare, upon application of a health maintenance organization, determines is unusual and infrequently provided and is not necessary for the protection of individual health. Requires the Secretary to publish such determinations in the Federal Register.

Allows HMOs to provide services to full-time students at accredited institutions of higher education for payments that are not fixed under community rating systems.

Requires HMOs to have certain administrative and managerial arrangements and capabilities.

Requires HMOs to carry out enrollment activities of Medicaid beneficiaries in accordance with procedures developed by the Secretary in regulations.

Exempts public HMOs from the requirements that at least one-third of the membership of the policy making body of an HMO be members of the organization and that the body include equitable representation from medically underserved populations served by the HMO. Requires public HMOs to have advisory boards which meet such requirements. Permits the delegation of policy authority to such boards.

Allows Federal support for HMO feasibility studies regardless of the financial position of the applicant HMO.

Authorizes up to $1,000,000 for the establishment of a HMO or $6000,000 for a project to significantly expand the membership of, or areas served by a HMO.

Increases the aggregate amount of principal of loans which may be made or guaranteed, or both, for the initial cost of operation of an HMO.

Requires employers that are required to offer their employees the option of membership in a qualified HMO to arrange, upon employee request, for employees' contributions for such membership to be paid through payroll deductions, if such employers already provide: (1) payroll deductions as a means of paying employees' contributions for health benefits or (2) a health benefits plan to which an employee contribution is not required.

Allows funds under the "Migrant Health" and "Community Health Centers" sections of the Public Health Service Act to be used for grants to migrant and community health centers which are not HMOs for the planning and development or the provision of health services on a prepaid basis.

Authorizes the Secretary to make loans to HMOs for projects for the acquisition or construction of ambulatory health care facilities and for the acquisition facilities acquired or constructed with such loans and to guarantee to non-Federal lenders and the Federal Financing Bank: (1) their loans to nonprofit private HMOs for such projects; and (2) their loans to private HMOs for such projects which will serve medically underserved populations. Limits the aggregate amount of principal of such loans made or guaranteed. Authorizes the Secretary to make such loans in fiscal years 1978 and after, and only to such extent or in such amounts as are provided in advance in appropriation Acts. Authorizes the Secretary to take appropriate actions to protect the United States' interest in the event of a default on such loans or loan guarantees.

Directs the Secretary to establish a National Health Maintenance Organization Intern Program to provide training to individuals to become administrators, medical directors, or managers of or assume other managerial positions with, HMOs. Authorizes the Secretary to enter into contracts for such Program only for fiscal years 1979 and after, and only to such extent or in such amounts as are provided in advance by appropriation Acts.

Requires each HMO: (1) to file with the Secretary such information as the Secretary may require concerning the fiscal operations of the HMO; and (2) to make such information available to its members.

Amends Title XIX (Medicaid) of the Social Security Act to prohibit State and local officers or employees responsible for the expenditures of substantial amounts of funds under the State Medicaid plan from conducting specified business dealings in connection with the State program after leaving office.

Amends the capital expenditure review provisions of the Social Security Act to provide that HMOs be covered equally with other health care institutions.

Authorizes the Secretary to waive specified policy-making body composition requirements for certain HMOs which are part of certain employee health benefits plans and were in operation as of July 1, 1978. Allows eligible HOMs one and one-half years to apply for this waiver. Authorizes the Secretary to impose appropriate terms and conditions on such HMOs. Authorizes the Secretary to require employers to offer two HMO of the same type as an HMO which serves an area in which such employers have at least 25 employees and which has received a waiver.