[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4227 Introduced in House (IH)]

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114th CONGRESS
  1st Session
                                H. R. 4227

      To enhance beneficiary and provider protections and improve 
 transparency in the Medicare Advantage market, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           December 10, 2015

 Ms. DeLauro introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
    and Commerce, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
      To enhance beneficiary and provider protections and improve 
 transparency in the Medicare Advantage market, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare Advantage Bill of Rights 
Act of 2015''.

SEC. 2. LIMITATION ON REMOVAL OF MEDICARE ADVANTAGE PROVIDERS BY MA 
              ORGANIZATIONS.

    (a) Limitation.--Section 1852(d) of the Social Security Act (42 
U.S.C. 1395w-22(d)) is amended by adding at the end the following:
            ``(7) Limitation on removal of providers from ma plans by 
        ma organizations.--
                    ``(A) Removal of providers with cause.--Beginning 
                with plan year 2017, except as provided in subparagraph 
                (C), an MA organization offering an MA plan may only 
                remove a provider of services or a supplier from a 
                network of such plan if the organization has cause to 
                remove such provider or supplier.
                    ``(B) Cause to remove providers.--
                            ``(i) In general.--An MA organization 
                        offering an MA plan has cause to remove a 
                        provider of services or a supplier from a 
                        network of such plan if the Secretary 
                        determines that the provider or supplier is--
                                    ``(I) medically negligent;
                                    ``(II) in violation of any legal or 
                                contractual requirement applicable to 
                                the provider or supplier acting within 
                                the lawful scope of practice, including 
                                any participation or other requirement 
                                applicable to such provider or supplier 
                                under this title or under any 
                                contractual term for such plan; or
                                    ``(III) otherwise unfit to furnish 
                                items and services in accordance with 
                                requirements of this title.
                            ``(ii) Consideration of cost to ma 
                        organizations.--For purposes of subparagraph 
                        (A), cost to an MA organization offering an MA 
                        plan due to the participation of a provider of 
                        services or supplier in a network of such plan 
                        does not constitute cause for the MA 
                        organization to remove such provider or 
                        supplier from the network mid-year, and such 
                        cost may not be considered as a factor in favor 
                        of a determination that such organization has 
                        cause to remove the provider.
                    ``(C) Exception.--With respect to each upcoming 
                plan year, beginning with plan year 2017, an MA 
                organization offering an MA plan may only remove a 
                provider of services or supplier from a network of such 
                plan for reasons not specified in subparagraph (B)(i) 
                before the date that is 60 days before the first day of 
                the annual coordinated election period for such plan 
                year under section 1851(e)(3).
                    ``(D) Notice and appeal process.--
                            ``(i) In general.--Any removal of a 
                        provider of services or supplier from a network 
                        of an MA plan may occur only after the 
                        completion of a fair notice and appeal process 
                        that the Secretary shall establish by 
                        regulation. Such process shall require the MA 
                        organization to provide to such provider or 
                        supplier and to the Secretary an explanation of 
                        the reason or reasons for the removal.
                            ``(ii) Application.--
                                    ``(I) Application of new process.--
                                In the case of a removal of a provider 
                                of services or supplier from a network 
                                of an MA plan occurring on or after the 
                                effective date published in a final 
                                rule for such fair notice and appeal 
                                process, such process shall apply in 
                                lieu of the process for the termination 
                                or suspension of a provider contract 
                                under section 422.202(a) of title 42, 
                                Code of Federal Regulations.
                                    ``(II) Continuation of old 
                                process.--In the case of a removal of a 
                                provider of services or supplier from a 
                                network of an MA plan occurring before 
                                such effective date, the process for 
                                the termination or suspension of a 
                                provider contract under section 
                                422.202(a) of title 42, Code of Federal 
                                Regulations, shall apply.
                    ``(E) Participant notice and protection.--
                            ``(i) Notice to participants of provider 
                        removal.--Not less than 60 days before the date 
                        on which a provider of services or supplier is 
                        removed from a network of an MA plan, the MA 
                        organization offering such plan shall provide 
                        written notification of the removal to each 
                        individual enrolled in such plan receiving 
                        items or services from the provider or supplier 
                        during the plan year in effect on the date of 
                        removal or during the previous plan year. Such 
                        notification shall include at the minimum--
                                    ``(I) the names and telephone 
                                numbers of available in-network 
                                providers of services and suppliers 
                                offering items and services that are 
                                the same or similar to the items and 
                                services offered by the removed 
                                provider or supplier;
                                    ``(II) information regarding the 
                                options available to an individual 
                                enrolled in such plan to request the 
                                continuation of medical treatment or 
                                therapy with the removed provider or 
                                supplier; and
                                    ``(III) one or more customer 
                                service telephone numbers that an 
                                individual enrolled in such plan may 
                                access to obtain information regarding 
                                changes to the network of the plan.
                            ``(ii) Annual notice of change.--In 
                        addition to providing the notification of 
                        removal as required under clause (i), the MA 
                        organization offering such MA plan shall 
                        include such notification in the annual notice 
                        of change for the MA plan for the upcoming plan 
                        year.
                            ``(iii) Continuity of care.--In any case in 
                        which a provider of services or supplier is 
                        removed from a network of an MA plan, such plan 
                        shall ensure that the removal satisfies the 
                        continuity of care requirements under paragraph 
                        (1)(A) with respect to each individual enrolled 
                        in such plan receiving items or services from 
                        the provider or supplier during the plan year 
                        in effect on the date of removal or during the 
                        previous plan year.
                    ``(F) Rule of construction.--Nothing in this 
                paragraph shall be construed as affecting the ability 
                of a provider of services or supplier to decline to 
                participate in a network of an MA plan.
            ``(8) Transparency in measures used by ma organizations to 
        establish or modify provider networks.--
                    ``(A) In general.--Beginning with plan year 2017, 
                an MA organization offering an MA plan shall include 
                the information described in subparagraph (B)--
                            ``(i) in the annual bid information 
                        submitted by the MA organization with respect 
                        to the MA plan under section 1854; and
                            ``(ii) on the Internet Web Site for the MA 
                        plan.
                    ``(B) Information described.--The information 
                described in this subparagraph is the following:
                            ``(i) Information regarding the measures 
                        used by the MA organization to establish or 
                        modify the provider network of the MA plan, 
                        including measures of the quality and 
                        efficiency of providers. Such information shall 
                        include the specifications, methodology, and 
                        sample size of such measures.
                            ``(ii) Other information related to the 
                        establishment or modification of such provider 
                        network that the Secretary determines 
                        appropriate.
                    ``(C) Limitation.--The information described in 
                subparagraph (B) shall not include any individually 
                identifiable information of any provider or supplier of 
                services.''.
    (b) Enforcement.--
            (1) Sanctions for noncompliance.--Section 1857(g)(1) of the 
        Social Security Act (42 U.S.C. 1395w-27(g)(1)) is amended--
                    (A) in subparagraph (J), by striking ``or'';
                    (B) by redesignating subparagraph (K) as 
                subparagraph (L);
                    (C) by inserting after subparagraph (J) the 
                following new subparagraph:
                    ``(K) fails to comply with sections 1852(d)(7) or 
                1852(d)(8); or''; and
                    (D) in subparagraph (L) (as so redesignated), by 
                striking ``through (J)'' and inserting ``through (K)''.
            (2) Sanctions not applicable to part d.--Title XVIII of the 
        Social Security Act is amended--
                    (A) in section 1860D-12(b)(3)(E) (42 U.S.C. 1395w-
                112(b)(3)(E)), by striking ``paragraph (1)(F)'' and 
                inserting ``paragraphs (1)(F) and (1)(K)''; and
                    (B) in section 1894(e)(6)(B) (42 U.S.C. 
                1395eee(e)(6)(B)), by inserting ``(other than paragraph 
                (1)(K) of such section)'' after ``1857(g)(1)''.
    (c) Medicare Advantage Plan Compare Tool.--Not later than one year 
after the date of enactment of this Act, the Secretary of Health and 
Human Services shall take such measures as are necessary to ensure that 
the Medicare Advantage Compare Tool takes into account the preferences 
and utilization needs of such individuals.

SEC. 3. NETWORK ADEQUACY.

    (a) In General.--Section 1852(d) of the Social Security Act (42 
U.S.C. 1395w-22(d)), as amended by section 2, is amended by adding at 
the end the following:
            ``(9) Network adequacy requirements.--Beginning in plan 
        year 2017, notwithstanding any other provision of law, the 
        following shall apply:
                    ``(A) Provider availability.--When establishing a 
                plan network, a Medicare Advantage organization 
                offering an MA plan shall, among other factors 
                determined by the Secretary, consider the following:
                            ``(i) The anticipated enrollment in the 
                        plan.
                            ``(ii) The expected types of services 
                        provided and utilization of services by 
                        enrollees under the plan.
                            ``(iii) The number and types of providers 
                        needed to provide such services.
                            ``(iv) The number of network providers who 
                        are not accepting new patients.
                            ``(v) The location of providers and 
                        enrollees.
                            ``(vi) The full-time equivalent 
                        availability of a provider to provide such 
                        services.
                    ``(B) Provision of care in a timely manner.--A 
                Medicare Advantage organization offering an MA plan 
                shall ensure that providers are able to provide 
                services in a timely manner, as defined by the 
                Secretary, under the plan.
                    ``(C) Application of network access adequacy 
                standards.--In applying the network access adequacy 
                standards pursuant to paragraph (1), the Secretary 
                shall seek input from patient advocacy groups, 
                providers of services and suppliers, and MA plans under 
                this part.
                    ``(D) Certification.--Each plan year, a Medicare 
                Advantage organization shall certify to the Secretary, 
                with respect to each MA plan offered by the 
                organization, that the providers, including specialists 
                and subspecialists, in the plan network are able to 
                provide the services required under the organization's 
                contract with the Secretary under section 1857 with 
                respect to the offering of such plan and to meet the 
                needs of the enrollees within the plan service area 
                during the year.
                    ``(E) Annual reporting.--Each plan year, a Medicare 
                Advantage organization shall report to the Secretary 
                the following with respect to each MA plan offered by 
                the organization:
                            ``(i) Average wait time.--The average wait 
                        time for primary and specialty care for 
                        enrollees under the plan.
                            ``(ii) Utilization of out of network 
                        providers.--The utilization of out-of-network 
                        providers under the plan.
                            ``(iii) Average cost per patient.--The 
                        average annual spending per patient for primary 
                        and specialty care for enrollees under the 
                        plan.
                    ``(F) Certification.--In advance of the annual, 
                coordinated election period under section 1851(e)(3), a 
                Medicare Advantage organization shall certify to the 
                Secretary the accuracy of provider directories for each 
                plan offered by the organization.
                    ``(G) Network review.--The Secretary shall ensure 
                that the network of each MA plan offered by a Medicare 
                Advantage organization meets the network adequacy 
                guidelines established under this paragraph and under 
                section 422.112(a)(4) of title 42, Code of Federal 
                Regulations (or any successor regulation to such 
                section) at least once every 3 years or when a material 
                change in network occurs.''.
    (b) Enforcement.--Section 1857(g)(1)(K) of the Social Security Act 
(42 U.S.C. 1395w-27(g)(1)(K)), as added by section 2(b), is amended by 
striking ``or 1852(d)(8)'' and inserting ``, 1852(d)(8), or 
1852(d)(9)''.
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