26 which embody prepaid group practice (as defined in regulations) or other definitive arrangements which the Board finds will so far as practicable provide to enrollees the benefits of prepaid group practice; (b) the furnishing of services is assured through a contract between the Board and a nonprofit provider of all the services to be furnished by the organization, or through a contract between the Board and a nonprofit provider of some of the services and subcontracts or other arrangements between such provider and providers (profitmaking or nonprofit) of the other services; (c) the organization furnishes, as a minimum, all covered services described in part B (including such supporting services as the Board may have approved under section 27 (b)), other than institutional services, mental health services, or dental services; and with the approval of the Board it may furnish covered services which it is not required by this subsection to furnish, and may fur nish health services not covered by this title; (d) the organization furnishes services in such manner as to provide continuity of care and (when services. are furnished by different providers) ready referral of patients to such services and at such times as may be medically appropriate, and to the maximum extent feasible, makes all services readily accessible to enrollees who live in the specified services area; 27 (e) all eligible persons, living in or near a specified service area, are eligible to enroll in the organization, except that (1) the number of enrollees may be limited to avoid overtaxing the resources of the organization, and (2) such restrictions upon enrollment may be im posed as are approved by the Board as necessary to prevent undue adverse selection; (f) the organization provides for periodic consultation with representatives of its enrollees regarding the policies and operation of the organization; (g) the organization encourages health education of its enrollees and the development and use of preventive health services, and provides that a committee or committees of physicians associated with the organization promulgate medical standards, oversee the professional aspects of the delivery of care, perform the functions of a pharmacy and drug therapeutics committee, and monitor and review the utilization and quality of all health services (including drugs); (h) the organization, to the extent practicable and consistent with good medical practice employs allied health personnel and subprofessional and lay persons in the furnishing of services; for (i) premiums or other charges by the organization any services not paid for under this title are reasonable: and 1 2 3 4 5 6 7 8 9 10 28 (j) the organization undertakes, to the extent required by regulations, to arrange for reciprocal out-of area services by other comprehensive health service or ganizations, or to pay for health services furnished to its enrollees by other participating providers, in emer gencies, within or outside the specified services area of the organization. OTHER HEALTH SERVICE ORGANIZATIONS SEC. 48. Pursuant to an agreement with the Board con taining such terms and conditions with respect to the qualifi11 cations of personnel and other matters as the Board may 12 deem appropriate, any of the following is a qualified pro13 vider of such services as are specified in the agreement (a) a public or other nonprofit agency or organiza tion which furnishes health services as comprehensive as those specified in section 47 (c), but does not meet all other requirements of section 47; (b) a public or other nonprofit center which (1) furnishes, as a minimum, the services of two or more physicians engaged in general or family practice, the services of nurses and supporting personnel, and basic laboratory services, which the Board finds sufficient for the primary medical care of a substantial population living in the vicinity of the center, and (2) has arrangements with other providers of services which 29 13 14 the Board finds assure to the population served by the center, on a coordinated basis, all components of health services as compresensive as those specified in section 47 (c); (c) a public or other nonprofit mental health center or mental health day care service; or (d) a State or local public health agency furnishing preventive or diagnostic services, a medical or dental group practice or clinic, a diagnostic and treatment center, or another organization or agency furnishing health services to ambulatory patients. MISCELLANEOUS PROVIDERS SEC. 49. (a) An independent pathology laboratory is a qualified provider of diagnostic pathology services if 15 (whether or not it is engaged in transactions in interstate 16 commerce) it meets the requirements established by or pur17 suant to section 353 of the Public Health Service Act. An 18 independent radiology service is a qualified provider of 19 diagnostic and therapeutic radiology if it meets all applicable 20 requirements of the law of the State in which the services are furnished, and such other requirements as the Board 22 finds necessary in the interest of the quality of care and the 21 23 safety of eligible persons. 24 25 (b) A provider of drugs, devices, appliances, or equip ment is a qualified provider if he meets all applicable re 30 1 quirements of the Federal Food, Drug, and Cosmetic Act 2 and of the law of the State in which the provider is situated, 3 and such other requirements as the Board finds necessary in 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 the interest of the quality of care and the safety of eligible persons. (c) A provider of ambulance services is a qualified provider if he meets all applicable requirements of the law of the State in which the services are furnished, and such other requirements as the Board finds necessary in the inter est of the quality of care and the safety of eligible persons. (d) A Christian Science Sanitorium is a qualified provider of services specified in regulations prescribed under section 24 (a) if it is operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Massachusetts. UTILIZATION REVIEW SEC. 40. A utilization review plan of a general or psychiatric hospital or a skilled nursing home shall be considered sufficient if it provides (a) for the periodic review on a sample or other basis (and the maintenance of adequate records of such 21 review) of admissions to the institutions, the duration of stays, and the professional services (including drugs) furnished, (1) with respect to the medical necessity of the services, and (2) for the purpose of promoting the most efficient use of available health facilities and |