HR 9336 — Better Care, Better Cost Act

(a) State option to use managed care (1) Use of medicaid managed care organizations and primary care case managers (A) In general Subject to the succeeding provisions of this section, and notwithstanding paragraph (1), (10)(B), or (23)(A) of section 1396a(a) of this title, a State— (i) may require an individual who is eligible for medical assistance under the State plan under this subchapter to enroll with a managed care entity as a condition of receiving such assistance (and, with respect to assistance furnished by or under arrangements with such entity, to receive such assistance through the entity), if— (I) the entity and the contract with the State meet the applicable requirements of this section and section 1396b(m) of this title or section 1396d(t) of this title, and (II) the requirements described in the succeeding paragraphs of this subsection are met; and (ii) may restrict the number of provider agreements with managed care entities under the State plan if such restriction does not substantially impair access to services. (B) “Managed care entity” defined In this section, the term “managed care entity” means— (i) a medicaid managed care organization, as defined in section 1396b(m)(1)(A) of this title, that provides or arranges for services for enrollees under a contract pursuant to section 1396b(m) of this title; and (ii) a primary care case manager, as defined in section 1396d(t)(2) of this title. (2) Special rules (A) Exemption of certain children with special needs A State may not require under paragraph (1) the enrollment in a managed care entity of an individual under 19 years of age who— (i) is eligible for supplemental security income under subchapter XVI; (ii) is described in section 701(a)(1)(D) of this title; (iii) is described in section 1396a(e)(3) of this title; (iv) is receiving foster care or adoption assistance under part E of subchapter IV; or (v) is in foster care or otherwise in an out-of-home placement. (B) Exemption of medicare beneficiaries A State may not require under paragraph (1) the enrollment in a managed care entity of an individual who is a qualified medicare beneficiary (as defined in section 1396d(p)(1) of this title) or an individual otherwise eligible for benefits under subchapter XVIII. (C) Indian enrollment A State may not require under paragraph (1) the enrollment in a managed care entity of an individual who is an Indian (as defined in section 4(c) 1 of the Indian Health Care Improvement Act of 1976 (25 U.S.C. 1603(c)) unless the entity is one of the following (and only if such entity is participating under the plan): (i) The Indian Health Service. (ii) An Indian health program operated by an Indian tribe or tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health Service pursuant to the Indian Self-Determination Act [25 U.S.C. 5321 et seq.]. (iii) An urban Indian health program operated by an urban Indian organization pursuant to a grant or contract with the Indian Health Service pursuant to title V of the Indian Health Care Improvement Act [25 U.S.C. 1651 et seq.]. (3) Choice of coverage (A) In general A State must permit an individual to choose a managed care entity from not less than two such entities that meet the applicable requirements of this section, and of section 1396b(m) of this title or section 1396d(t) of this title. (B) State option At the option of the State, a State shall be considered to meet the requirements of subparagraph (A) in the case of an individual residing in a rural area, if the State requires the individual to enroll with a managed care entity if such entity— (i) permits the individual to receive such assistance through not less than two physicians or case managers (to the extent that at least two physicians or case managers are available to provide such assistance in the area), and (ii) permits the individual to obtain such assistance from any other provider in appropriate circumstances (as establ...