Medicare Provider-Sponsored Organization Act of 1997

referredUnited States· United States Congress· EN

Introduced

21 January 1997

Last action

30 January 1997 · Referred

Status

Referred to the Subcommittee on Health and Environment.

Summary

Medicare Provider-Sponsored Organization Act of 1997 - Amends title XVIII (Medicare) of the Social Security Act (SSA) to give Medicare beneficiaries the option of receiving Medicare coverage through enrollment with provider-sponsored organizations (PSOs) organized and licensed under State law, and certified as meeting certain Federal standards. Requires a PSO to: (1) deliver a spectrum of health care services (including basic hospital and physicians services) to enrolled purchasers; and (2) provide a substantial proportion of the health care items and services under its Medicare contract through the provider or affiliated group of providers composing the organization. (Sec. 2) Provides for direct Federal Medicare certification as a qualified PSO through calendar 2001. Authorizes State licensure of PSOs after January 1, 2002, only if: (1) State financial solvency and capital adequacy standards are identical with Federal standards; and (2) State licensure standards are substantially equivalent to Federal standards. Allows a PSO seeking to operate under a full-risk contract or a partial risk contract to apply to the Secretary of Health and Human Services for waiver of State licensure if: (1) the State has failed to act on the PSO's State application within a certain period of time; or (2) the State has denied the PSO's application, but the State's licensing standards or review process impose unreasonable barriers to market entry. Declares that a fiscally sound PSO meets Medicare financial solvency requirements. Prescribes general requirements for a PSO's ongoing quality assurance program (including case-by-case utilization review). Treats such requirements as met if the PSO is accredited by a private organization under a process approved by the Secretary. Sets forth physician-participation procedure requirements and other special rules. Directs the Secretary to issue regulations regarding qualified PSO standards, which shall preempt State law. (Sec. 3) Authorizes the Secretary to pay all Medicare health plans on a partial risk basis. (Sec. 4) Treats Medicare-eligible organizations, including PSOs, as meeting the "50-50" enrollment composition rule (which requires that a health plan's Medicare and Medicaid enrollees cannot exceed 50 percent of its total enrollment) if they demonstrate: (1) their capability of providing coordinated care in accordance with the quality assurance standards established by this Act; and (2) their experience providing coordinated care to enrollees of a health plan or State Medicaid plan. (Sec. 5) Provides that a health maintenance organization under Medicaid includes a public or private organization which may be a PSO. (Sec. 6) Directs the Secretary to provide for demonstration projects in at least ten States that permit Medicaid programs to be treated as Medicare-eligible organizations for individuals eligible to enroll with a Medicare organization and also eligible for Medicaid, for the purpose of demonstrating the delivery of primary, acute, and long-term care through an integrated delivery network that emphasizes noninstitutional care. (Sec. 7) Prescribes rules on coverage of emergency services by all Medicare plans. (Sec. 8) Limits State law restrictions on managed care arrangements; but exempts from such restrictions any law that has the effect of preventing involuntary denial of life-saving medical treatment when such denial would cause the patient's involuntary death pending transfer to a health care provider willing to provide such treatment. (Sec. 9) Requires the Department of Justice and the Federal Trade Commission to provide jointly for the development and publication of explicit, binding guidelines on the application of antitrust laws to PSO activities, addressing PSO formation, development, and operation issues of PSOs and facilitating their development and operation.

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Timeline

21 January 1997
Introduced
Referred to House Commerce
Source: IntroReferral
21 January 1997
Introduced
Referred to the Committee on Commerce, and in addition to the Committees on Ways and Means, and the Judiciary, 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.
Source: IntroReferral
21 January 1997
Introduced
Introduced in House
Source: IntroReferral
21 January 1997
Introduced
Introduced in House
Source: IntroReferral
27 January 1997
Referred
Referred to the Subcommittee on Health.
Source: Committee
30 January 1997
Referred
Referred to the Subcommittee on Health and Environment.
Source: Committee

Votes

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Versions

Introduced in House · 21 January 1997 · Download file

Documents

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Introduced in House (text)

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Introduced in House (text)
Introduced in House · EN · 21 January 1997
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Introduced in House (PDF)
Introduced in House · EN · 21 January 1997
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Introduced in House
summary · EN · 21 January 1997
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Sources

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Official source: https://www.congress.gov/bill/105th-congress/house-bill/475
Open data entity: https://api.congress.gov/v3/bill/105/hr/475
us · 105-hr-475 · source updated 3 June 2026