Page:United States Statutes at Large Volume 101 Part 2.djvu/917

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101 STAT. 1330-123
101 STAT. 1330-123
PUBLIC LAW 100-000—MMMM. DD, 1987

PUBLIC LAW 100-203—DEC. 22, 1987

101 STAT. 1330-123

(1) The Secretary may not enter into an agreement with an eligible organization to conduct a demonstration project under t h ^ section unless the organization meets the requirements of this subsection and subsection (d) with respect to members enrolled with the organization under this section. (2) The organization shall have an open enrollment period for the enrollment of individuals under this section. The duration of such period of enrollment and any other requirement pertaining to enrollment or termination of enrollment shall be specified in the agreement with the organization. (3) The organization must provide to members enrolled with the organization under this section, through providers and other persons that meet the applicable requirements of titles XVIII and XIX of the Social Security Act, community nursing and ambulatory care (as defined in subsection O^XD) which is generally available to individuals residing in the geographic area served by the organization, except that the organization may provide such members with such additional health care services as the members may elect, at their option, to have covered. (4) The organization must make community nursing and ambulatory care (and such other health care services as such individuals have contracted for) available and accessible to each individual enrolled with the organization under this section, within the area served by the organization, with reasonable promptness and in a manner which assures continuity. (5) Section 1876(c)(5) of the Social Security Act shall apply to organizations under this section in the same manner as it applies to organizations under section 1876 of such Act. (6) The organization must have arrangements, established in accordance with regulations of the Secretary, for an ongoing quality assurance program for health care services it provides to such individuals under the demonstration project conducted under this section, which program (A) stresses health outcomes and (B) provides review by health care professionals of the process followed in the provision of such health care services. (7) Under a demonstration project under this section— (A) the Secretary could require the organization to provide financial or other assurances (including financial risksharing) that minimize the inappropriate substitution of other services under title XVIII of such Act for community nursing services; and (B) if the Secretary determines that the organization has failed to perform in accordance with the requirements of the project (including meeting fincmcial responsibility requirements under the project, any pattern of disproportionate or inappropriate institutionalization) the Secretary shall, after notice, terminate the project. (d) DETERMINATION OF PER CAPITA PAYMENT RATES.—

(1) The Secretary shall determine for each 12-month period in which a demonstration project is conducted under this section, and shall announce (in a mcmner intended to provide notice to interested parties) not later than three months before the beginning of such period, with respect to each eligible organization conducting a demonstration project under this section, a per capita rate of payment for each class of individuals who are enrolled with such organization who are entitled to benefits