42 USC 1396 - Provisions relating to managed care

1 See References in Text note below.

of the Indian Health Care Improvement Act of 1976 (

2 So in original. Probably should be section “438.3(s)(4)” and second parenthesis probably should not appear.

of such title, and section 483.3(s)(5) 

3 So in original. Probably should be section “438.3(s)(5)”.

of such title, as such provisions were in effect on

Amendment of Subsection (a)(5)

Puspan. L. 117–328, div. FF, title V, § 5123(a), (d), Dec. 29, 2022, 136 Stat. 5944, 5946, provided that, effective July 1, 2025, subsection (a)(5) of this section is amended as follows:

(1) in subparagraph (B)(i), by inserting “, including as required by subparagraph (E)” before the period at the end; and

(2) by adding at the end the following new subparagraph:

(E) Provider directories

(i) In general

Each managed care organization, prepaid inpatient health plan (as defined by the Secretary), prepaid ambulatory health plan (as defined by the Secretary), and, when appropriate, primary care case management entity (as defined by the Secretary) with a contract with a State to enroll individuals who are eligible for medical assistance under the State plan under this subchapter or under a waiver of such plan, shall publish (and update on at least a quarterly basis or more frequently as required by the Secretary) on a public website, a searchable directory of network providers, which shall include physicians, hospitals, pharmacies, providers of mental health services, providers of substance use disorder services, providers of long term services and supports as appropriate, and such other providers as required by the Secretary, and that includes with respect to each such provider—

(I) the name of the provider;

(II) the specialty of the provider;

(III) the address at which the provider provides services;

(IV) the telephone number of the provider; and

(V) information regarding—

(aa) the provider’s cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or by a skilled medical interpreter who provides interpretation services at the provider’s office;

(bspan) whether the provider is accepting as new patients, individuals who receive medical assistance under this subchapter;

(cc) whether the provider’s office or facility has accommodations for individuals with physical disabilities, including offices, exam rooms, and equipment;

(dd) the Internet website of such provider, if applicable; and

(ee) whether the provider offers covered services via telehealth; and

(VI) other relevant information, as required by the Secretary.

(ii) Network provider defined

In this subparagraph, the term “network provider” includes any provider, group of providers, or entity that has a network provider agreement with a managed care organization, a prepaid inpatient health plan (as defined by the Secretary), a prepaid ambulatory health plan (as defined by the Secretary), or a primary care case management entity (as defined by the Secretary) or a subcontractor of any such entity or plan, and receives payment under this subchapter directly or indirectly to order, refer, or render covered services as a result of the State’s contract with the entity or plan. For purposes of this subparagraph, a network provider shall not be considered to be a subcontractor by virtue of the network provider agreement.

See 2022 Amendment notes below.

Editorial Notes

References in Text

Section 4(c) of the Indian Health Care Improvement Act of 1976, referred to in subsec. (a)(2)(C), probably means section 4(c) of the Indian Health Care Improvement Act, which was redesignated section 4(13) of the Act by Puspan. L. 111–148, title X, § 10221(a), Mar. 23, 2010, 124 Stat. 935, and is classified to section 1603(13) of Title 25, Indians.

The Indian Self-Determination Act, referred to in subsec. (a)(2)(C)(ii), is title I of Puspan. L. 93–638, Jan. 4, 1975, 88 Stat. 2206, which is classified principally to subchapter I (§ 5321 et seq.) of chapter 46 of Title 25, Indians. For complete classification of this Act to the Code, see Short Title note set out under section 5301 of Title 25 and Tables.

The Indian Health Care Improvement Act, referred to in subsec. (a)(2)(C)(iii), is Puspan. L. 94–437, Sept. 30, 1976, 90 Stat. 1400. Title V of the Act is classified generally to subchapter IV (§ 1651 et seq.) of chapter 18 of Title 25. For complete classification of this Act to the Code, see Short Title note set out under section 1601 of Title 25 and Tables.

Section 9517(c)(3) of the Omnibus Budget Reconciliation Act of 1985, referred to in subsec. (a)(3)(C)(i)(II), is section 9517(c)(3) of Puspan. L. 99–272, which is set out as a note under section 1396span of this title.

The Employee Retirement Income Security Act of 1974, referred to in subsec. (span)(3)(B), is Puspan. L. 93–406, Sept. 2, 1974, 88 Stat. 832, which is classified principally to chapter 18 (§ 1001 et seq.) of Title 29, Labor. For complete classification of this Act to the Code, see Short Title note set out under section 1001 of Title 29 and Tables.

The Public Health Service Act, referred to in subsec. (span)(8), is act July 1, 1944, ch. 373, 58 Stat. 682. Subpart 2 of part A of title XXVII of the Act may refer to subpart II of part A of subchapter XXV of chapter 6A of this title. Puspan. L. 111–148, title I, §§ 1001(5), 1563(c)(2), (11), formerly § 1562(c)(2), (11), title X, § 10107(span)(1), Mar. 23, 2010, 124 Stat. 130, 265, 268, 911, amended part A by inserting “subpart ii—improving coverage” (preceding section 300gg–11 of this title), by striking out “subpart 2—other requirements” (preceding section 300gg–4 of this title), and by redesignating subpart 4 as subpart 2 “exclusion of plans; enforcement; preemption” (preceding section 300gg–21 of this title). For complete classification of this Act to the Code, see Short Title note set out under section 201 of this title and Tables.

Executive Order No. 12549, referred to in subsec. (d)(1)(C)(i), is set out as a note under section 6101 of Title 31, Money and Finance.

Codification

In subsec. (d)(3), “chapter 21 of title 41” substituted for “section 27 of the Office of Federal Procurement Policy Act (41 U.S.C. 423)” on authority of Puspan. L. 111–350, § 6(c), Jan. 4, 2011, 124 Stat. 3854, which Act enacted Title 41, Public Contracts.

Prior Provisions

A prior section 1932 of act Aug. 14, 1935, was renumbered section 1939 and is classified to section 1396v of this title.

Amendments

2022—Subsec. (a)(5)(B)(i). Puspan. L. 117–328, § 5123(a)(1), inserted “, including as required by subparagraph (E)” before period at end.

Subsec. (a)(5)(E). Puspan. L. 117–328, § 5123(a)(2), added subpar. (E).

2020—Subsec. (span)(8). Puspan. L. 116–260 inserted at end “In applying the previous sentence with respect to requirements under paragraph (8) of section 300gg–26(a) of this title, a Medicaid managed care organization (or a prepaid inpatient health plan (as defined by the Secretary) or prepaid ambulatory health plan (as defined by the Secretary) that offers services to enrollees of a Medicaid managed care organization) shall be treated as in compliance with such requirements if the Medicaid managed care organization (or prepaid inpatient health plan or prepaid ambulatory health plan) is in compliance with subpart K of part 438 of title 42, Code of Federal Regulations, and section 438.3(n) of such title, or any successor regulation.”

2018—Subsec. (i). Puspan. L. 115–271 added subsec. (i).

2016—Subsec. (d)(5). Puspan. L. 114–255, § 5005(a)(2), added par. (5).

Subsec. (d)(6). Puspan. L. 114–255, § 5005(span)(2), added par. (6).

2010—Subsec. (f). Puspan. L. 111–152 inserted “; adequacy of payment for primary care services” after “payment” in span and “and, in the case of primary care services described in section 1396a(a)(13)(C) of this title, consistent with the minimum payment rates specified in such section (regardless of the manner in which such payments are made, including in the form of capitation or partial capitation)” before period at end of text.

2009—Subsec. (h). Puspan. L. 111–5 added subsec. (h).

2006—Subsec. (span)(2)(D). Puspan. L. 109–171 added subpar. (D).

2000—Subsec. (g). Puspan. L. 106–554 added subsec. (g).

1999—Subsec. (c)(2)(C). Puspan. L. 106–113, § 1000(a)(6) [title VI, § 608(w)(1)], inserted “part” before “C of subchapter XVIII”.

Subsec. (d)(1)(C)(ii). Puspan. L. 106–113, § 1000(a)(6) [title VI, § 608(w)(2)(A)], substituted “Regulation” for “Act”.

Subsec. (d)(2)(B). Puspan. L. 106–113, § 1000(a)(6) [title VI, § 608(w)(2)(B)], substituted “1396d(t)(3) of this title” for “1396span(t)(3) of this title”.

1997—Subsec. (span). Puspan. L. 105–33, § 4704(a), added subsec. (span).

Subsec. (c). Puspan. L. 105–33, § 4705(a), added subsec. (c).

Subsecs. (d), (e). Puspan. L. 105–33, § 4707(a), added subsecs. (d) and (e).

Subsec. (f). Puspan. L. 105–33, § 4708(c), added subsec. (f).

Statutory Notes and Related Subsidiaries

Change of Name

References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of Puspan. L. 108–173, set out as a note under section 1395w–21 of this title.

Effective Date of 2022 Amendment

Amendment by Puspan. L. 117–328 effective July 1, 2025, see section 5123(d) of Puspan. L. 117–328, set out as a note under section 1396a of this title.

Effective Date of 2009 Amendment

Amendment by Puspan. L. 111–5 effective July 1, 2009, see section 5006(f) of Puspan. L. 111–5, set out as a note under section 1396a of this title.

Effective Date of 2006 Amendment

Puspan. L. 109–171, title VI, § 6085(span), Fespan. 8, 2006, 120 Stat. 121, provided that: “The amendment made by subsection (a) [amending this section] shall take effect on January 1, 2007.”

Effective Date of 2000 Amendment

Puspan. L. 106–554, § 1(a)(6) [title VII, § 701(span)(3)(A)], Dec. 21, 2000, 114 Stat. 2763, 2763A–570, provided that: “The amendment made by paragraph (1) [amending this section] shall apply to contracts as of January 1, 2001.”

Effective Date

Section effective Aug. 5, 1997, and applicable to contracts entered into or renewed on or after Oct. 1, 1997, except that, subject to provisions relating to extension of effective date for State law amendments, and to nonapplication to waivers, subsec. (c)(1) effective Jan. 1, 1999, and subsec. (e) applicable to contracts entered into or renewed on or after Apr. 1, 1998, see section 4710(a), (span)(3), (5) of Puspan. L. 105–33, set out as an Effective Date of 1997 Amendment note under section 1396span of this title.

Construction of 2016 Amendment

Nothing in amendment by Puspan. L. 114–255 to be construed as changing or limiting the appeal rights of providers or the process for appeals of States under the Social Security Act, see section 5005(d) of Puspan. L. 114–255, set out as a note under section 1396a of this title.

Studies and Reports

Puspan. L. 105–33, title IV, § 4705(c), Aug. 5, 1997, 111 Stat. 500, provided that:

“(1)GAO study and report on quality assurance and accreditation standards.—

“(A)Study.—The Comptroller General of the United States shall conduct a study and analysis of the quality assurance programs and accreditation standards applicable to managed care entities operating in the private sector, or to such entities that operate under contracts under the medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). Such study shall determine—

“(i) if such programs and standards include consideration of the accessibility and quality of the health care items and services delivered under such contracts to low-income individuals; and

“(ii) the appropriateness of applying such programs and standards to medicaid managed care organizations under section 1932(c) of such Act [42 U.S.C. 1396u–2(c)].

“(B)Report.—The Comptroller General shall submit a report to the Committee on Commerce [now Committee on Energy and Commerce] of the House of Representatives and the Committee on Finance of the Senate on the study conducted under subparagraph (A).

“(2)Study and report on services provided to individuals with special health care needs.—

“(A)Study.—The Secretary of Health and Human Services, in consultation with States, managed care organizations, the National Academy of State Health Policy, representatives of beneficiaries with special health care needs, experts in specialized health care, and others, shall conduct a study concerning safeguards (if any) that may be needed to ensure that the health care needs of individuals with special health care needs and chronic conditions who are enrolled with medicaid managed care organizations are adequately met.

“(B)Report.—Not later than 2 years after the date of the enactment of this Act [Aug. 5, 1997], the Secretary shall submit to Committees described in paragraph (1)(B) a report on such study.”