Section 300e–9(d) of this title, referred to in subsec. (b)(1), was redesignated section 300e–9(c) of this title by Pub. L. 100–517, § 7(b),
Section 300e(c)(8) of this title, referred to in subsec. (i)(3)(C)(i), was redesignated section 300e(c)(7) of this title by Pub. L. 100–517, § 5(b),
Section 1320c–3(a)(4)(C) of this title, referred to in subsec. (i)(7)(A), was repealed by Pub. L. 112–40, title II, § 261(c)(2)(A)(ii),
2015—Subsec. (h)(5)(C)(ii). Pub. L. 114–10, § 209(a)(1), substituted “Subject to clause (iv), for any” for “For any” in introductory provisions.
Subsec. (h)(5)(C)(iii)(I). Pub. L. 114–10, § 209(a)(2), inserted “cost plan service” after “With respect to any portion of the”.
Subsec. (h)(5)(C)(iii)(II). Pub. L. 114–10, § 209(a)(3), inserted “cost plan service” after “With respect to any other portion of such” in introductory provisions.
Subsec. (h)(5)(C)(iv), (v). Pub. L. 114–10, § 209(a)(4), added cls. (iv) and (v).
2014—Subsec. (h)(5)(C)(ii). Pub. L. 113–93 substituted “
2013—Subsec. (h)(5)(C)(ii). Pub. L. 113–67 substituted “
Pub. L. 112–240 substituted “
2011—Subsec. (i)(7)(A). Pub. L. 112–40 substituted “quality improvement” for “utilization and quality control peer review”.
2010—Subsec. (h)(5)(C)(ii). Pub. L. 111–148 substituted “
2008—Subsec. (h)(5)(C)(ii). Pub. L. 110–275, § 167(a), substituted “
Subsec. (h)(5)(C)(ii)(I), (II). Pub. L. 110–275, § 167(b), inserted “, provided that all such plans are not offered by the same Medicare Advantage organization” after “clause (iii)”.
Subsec. (h)(5)(C)(iii)(I). Pub. L. 110–275, § 167(c), inserted “that are not in another Metropolitan Statistical Area with a population of more than 250,000” after “such Metropolitan Statistical Area” and inserted “If the service area includes a portion in more than 1 Metropolitan Statistical Area with a population of more than 250,000, the minimum enrollment determination under the preceding sentence shall be made with respect to each such Metropolitan Statistical Area (and such applicable contiguous counties to such Metropolitan Statistical Area).” at end.
2007—Subsec. (h)(5)(C)(ii). Pub. L. 110–173 substituted “
2003—Subsec. (c)(2)(B). Pub. L. 108–173, § 736(d)(2)(A), substituted “significant” for “signifcant” in introductory provisions.
Subsec. (c)(5)(B). Pub. L. 108–173, § 940(b)(2)(B), which directed amendment of subsec. (b)(5)(B) by inserting at end “The provisions of section 1395ff(b)(1)(E)(iii) of this title shall apply with respect to dollar amounts specified in the first 2 sentences of this subparagraph in the same manner as they apply to the dollar amounts specified in section 1395ff(b)(1)(E)(i) of this title.”, was executed by making the insertion at end of subsec. (c)(5)(B), to reflect the probable intent of Congress. Subsec. (b) does not contain a par. (5)(B).
Subsec. (h)(5)(C). Pub. L. 108–173, § 234, amended subpar. (C) generally. Prior to amendment, subpar. (C) read as follows: “The Secretary may not extend or renew a reasonable cost reimbursement contract under this subsection for any period beyond
Subsec. (j)(2). Pub. L. 108–173, § 736(d)(2)(B), substituted “this section” for “this setion”.
2000—Subsec. (h)(5)(B), (C). Pub. L. 106–554 added subpar. (B) and redesignated former subpar. (B) as (C).
1999—Subsec. (h)(5)(B). Pub. L. 106–113 substituted “2004” for “2002”.
1997—Subsec. (f)(1). Pub. L. 105–33, § 4002(a)(1), substituted “For contract periods beginning before
Subsec. (f)(2). Pub. L. 105–33, § 4002(a)(2), substituted “Subject to paragraph (4), the Secretary” for “The Secretary”.
Subsec. (f)(4). Pub. L. 105–33, § 4002(a)(3), added par. (4).
Subsec. (h)(5). Pub. L. 105–33, § 4002(b)(2)(A), added par. (5).
Subsec. (k). Pub. L. 105–33, § 4002(b)(1), added subsec. (k).
1996—Subsec. (i)(1). Pub. L. 104–191, § 215(a)(1), substituted “in accordance with procedures established under paragraph (9), the Secretary may at any time terminate any such contract or may impose the intermediate sanctions described in paragraph (6)(B) or (6)(C) (whichever is applicable) on the eligible organization if the Secretary determines that the organization—” for “the Secretary may terminate any such contract at any time (after such reasonable notice and opportunity for hearing to the eligible organization involved as he may provide in regulations), if he finds that the organization—” in introductory provisions, added subpars. (A) to (C), and struck out former subpars. (A) to (C) which read as follows:
“(A) has failed substantially to carry out the contract,
“(B) is carrying out the contract in a manner inconsistent with the efficient and effective administration of this section, or
“(C) no longer substantially meets the applicable conditions of subsections (b), (c), (e), and (f) of this section.”
Subsec. (i)(6)(B). Pub. L. 104–191, § 215(a)(4), struck out concluding provisions which read as follows: “The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (i) in the same manner as they apply to a civil money penalty or proceeding under section 1320a–7a(a) of this title.”
Subsec. (i)(6)(C). Pub. L. 104–191, § 215(a)(2), added subpar. (C).
Subsec. (i)(6)(D). Pub. L. 104–191, § 231(g), added subpar. (D).
Subsec. (i)(7)(A). Pub. L. 104–191, § 215(b), substituted “a written agreement” for “an agreement”.
Subsec. (i)(9). Pub. L. 104–191, § 215(a)(3), added par. (9).
1994—Subsec. (a)(1)(E)(ii)(I). Pub. L. 103–432, § 157(b)(4), struck out comma after “contributed to”.
Subsec. (a)(3). Pub. L. 103–432, § 157(b)(1), substituted “subsections (c)(2)(B)(ii) and (c)(7)” for “subsection (c)(7)”.
Subsec. (c)(5)(B). Pub. L. 103–296 inserted at end “In applying sections 405(b) and 405(g) of this title as provided in this subparagraph, and in applying section 405(l) of this title thereto, any reference therein to the Commissioner of Social Security or the Social Security Administration shall be considered a reference to the Secretary or the Department of Health and Human Services, respectively.”
1990—Subsec. (a)(1)(E). Pub. L. 101–508, § 4204(e)(1), designated existing provisions as cl. (i) and added cl. (ii).
Subsec. (a)(6). Pub. L. 101–508, § 4204(c)(2), substituted “subsections (c)(2)(B)(ii) and (c)(7)” for “subsection (c)(7)”.
Subsec. (c)(2). Pub. L. 101–508, § 4204(c)(1), designated existing provisions as subpar. (A), redesignated former subpars. (A) and (B) and former cls. (i) and (ii) as cls. (i) and (ii) and subcls. (I) and (II), respectively, and added subpar. (B).
Subsec. (c)(8). Pub. L. 101–508, § 4206(b)(1), added par. (8).
Subsec. (i)(6)(A)(vi). Pub. L. 101–508, § 4204(a)(2), inserted “or paragraph (8)” after “(g)(6)(A)”.
Subsec. (i)(8). Pub. L. 101–508, § 4204(a)(1), added par. (8).
Subsec. (j)(1)(A). Pub. L. 101–508, § 4204(d)(1)(A), substituted “physicians’ services or renal dialysis services” for “physicians’ services”, “physician or provider of services or renal dialysis facility” for “physician” in three places, and “applicable participation agreement” for “participation agreement under section 1395u(h)(1) of this title”.
Subsec. (j)(2). Pub. L. 101–508, § 4204(d)(1)(B), substituted “physicians’ services or renal dialysis services” for “physicians’ services” in two places and “which are furnished to an enrollee of an eligible organization under this setion [sic] by a physician, provider of services, or renal dialysis facility who is not under a contract with the organization.” for “which—” and subpars. (A) and (B) which read as follows:
“(A) are emergency services or out-of-area coverage (described in clauses (iii) and (iv) of subsection (b)(2)(A) of this section), and
“(B) are furnished to an enrollee of an eligible organization under this section by a person who is not under a contract with the organization.”
1989—Subsec. (a)(1)(F). Pub. L. 101–239, § 6206(a)(1), added subpar. (F).
Subsec. (a)(5). Pub. L. 101–234, § 202(a), repealed Pub. L. 100–360, § 211(c)(3)(A), and provided that the provisions of law amended or repealed by such section are restored or revised as if such section had not been enacted, see 1988 Amendment note below.
Subsec. (c)(3)(A)(i). Pub. L. 101–239, § 6206(b)(1)(A), substituted “period or periods” for “30-day period”.
Subsec. (c)(3)(A)(ii). Pub. L. 101–239, § 6206(b)(1)(B), added cl. (ii) and struck out former cl. (ii) which read as follows: “For each area served by more than one eligible organization under this section, the Secretary (after consultation with such organizations) shall establish a single 30-day period each year during which all eligible organizations serving the area must provide for open enrollment under this section. The Secretary shall determine annual per capita rates under subsection (a)(1)(A) of this section in a manner that assures that individuals enrolling during such a 30-day period will not have premium charges increased or any additional benefits decreased for 12 months beginning on the date the individual’s enrollment becomes effective. An eligible organization may provide for such other open enrollment period or periods as it deems appropriate consistent with this section.”
Subsecs. (e)(1), (g)(3)(A). Pub. L. 101–234, § 201(a), repealed Pub. L. 100–360, § 202(f), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment notes below.
Subsec. (g)(5). Pub. L. 101–239, § 6212(c)(2), struck out “and during a period of not longer than four years” after first reference to “Secretary”.
Subsec. (i)(6)(A)(vii). Pub. L. 101–239, § 6411(d)(3)(A), added cl. (vii).
Subsec. (j). Pub. L. 101–239, § 6212(b)(1), added subsec. (j).
1988—Subsec. (a)(5). Pub. L. 100–360, § 211(c)(3)(B), amended second sentence generally. Prior to amendment, second sentence read as follows: “The portion of that payment to the organization for a month to be paid by the latter trust fund shall be equal to 200 percent of the sum of—
“(A) the product of (i) the number of such individuals for the month who have attained age 65, and (ii) the monthly actuarial rate for supplementary medical insurance for the month as determined under section 1395r(a)(1) of this title, and
“(B) the product of (i) the number of such individuals for the month who have not attained age 65, and (ii) the monthly actuarial rate for supplementary medical insurance for the month as determined under section 1395r(a)(4) of this title.”
Pub. L. 100–360, § 211(c)(3)(A), substituted “, the Federal Supplementary Medical Insurance Trust Fund, and the Federal Catastrophic Drug Insurance Trust Fund” for “and the Federal Supplementary Medical Insurance Trust Fund” in first sentence.
Subsec. (c)(3)(F). Pub. L. 100–360, § 411(c)(1), realigned margin with left margin of subpar. (G).
Subsec. (e)(1). Pub. L. 100–360, § 202(f)(1), inserted at end “The preceding sentence shall be applied separately with respect to covered outpatient drugs.”
Subsec. (f)(3). Pub. L. 100–647 redesignated par. (4) as (3) and struck out former par. (3) which read as follows:
“(A) An eligible organization described in subparagraph (B) may elect, for purposes of enrollment and residency requirements under this section and for determining the compliance of a subdivision, subsidiary, or affiliate described in subparagraph (B)(iii) with the requirement of paragraph (1) for the period before
“(B) An eligible organization described in this subparagraph is an eligible organization which—
“(i) is described in section 1396b(m)(2)(B)(iii) of this title;
“(ii) has members who have a collectively bargained contractual right to obtain health benefits from the organization;
“(iii) elects to provide benefits under a risk-sharing contract to individuals residing in a service area, who have a collectively bargained contractual right to obtain benefits from the organization, through a subdivision, subsidiary, or affiliate which itself is an eligible organization serving the area and which is owned or controlled by the parent eligible organization; and
“(iv) has assumed any risk of insolvency and quality assurance with respect to individuals receiving benefits through such a subdivision, subsidiary, or affiliate.”
Subsec. (f)(3)(A). Pub. L. 100–360, § 411(c)(6), formerly § 411(c)(5), as redesignated by Pub. L. 100–485, § 608(d)(19)(C), inserted “enrollment and residency requirements under this section and for” after “for purposes of” and substituted “described in subparagraph (B)(iii) who receives services through the subdivision” for “of the subdivision”.
Subsec. (f)(4). Pub. L. 100–647 redesignated par. (4) as (3).
Subsec. (g)(3)(A). Pub. L. 100–360, § 202(f)(2), substituted “rates” for “rate”.
Subsec. (g)(5). Pub. L. 100–360, § 411(c)(3), amended Pub. L. 100–203, § 4013, see 1987 Amendment note below.
Subsec. (i)(6)(A). Pub. L. 100–360, § 411(c)(4)(A), inserted “, in addition to any other remedies authorized by law,” after “the Secretary may provide” in concluding provisions.
Subsec. (i)(6)(B). Pub. L. 100–360, § 411(c)(4)(C), formerly § 411(c)(4)(B), as redesignated by Pub. L. 100–485, § 608(d)(19)(B)(ii), substituted “or proceeding under section 1320a–7a(a) of this title” for “under that section” in last sentence.
Subsec. (i)(6)(B)(i). Pub. L. 100–360, § 411(c)(4)(B), as added by Pub. L. 100–485, § 608(d)(19)(B)(i), (iii), inserted “of such subparagraph” after “(v)(I)”.
Pub. L. 100–360, § 224, inserted at end “plus, with respect to a determination under subparagraph (A)(ii), double the excess amount charged in violation of such subparagraph (and the excess amount charged shall be deducted from the penalty and returned to the individual concerned), and plus, with respect to a determination under subparagraph (A)(iv), $15,000 for each individual not enrolled as a result of the practice involved,”.
Subsec. (i)(7)(A). Pub. L. 100–360, § 411(e)(3), added Pub. L. 100–203, § 4039(h)(8)(A), (B), see 1987 Amendment note below.
Subsec. (i)(7)(B). Pub. L. 100–360, § 411(e)(3), added Pub. L. 100–203, § 4039(h)(8)(C), see 1987 Amendment note below.
1987—Subsec. (c)(3)(F). Pub. L. 100–203, § 4011(a)(1), added subpar. (F).
Subsec. (c)(3)(G). Pub. L. 100–203, § 4011(b)(1), added subpar. (G).
Subsec. (f)(3), (4). Pub. L. 100–203, § 4018(a), added par. (3) and redesignated former par. (3) as (4).
Subsec. (g)(4). Pub. L. 100–203, § 4012(b), struck out par. (4) which read as follows: “A risk-sharing contract under this subsection may, at the option of an eligible organization, provide that the Secretary—
“(A) will reimburse hospitals and skilled nursing facilities either for payment amounts determined in accordance with section 1395ww of this title, or, if applicable, for the reasonable cost (as determined under section 1395x(v) of this title) or other appropriate basis for payment established under this subchapter, of inpatient services furnished to individuals enrolled with such organization pursuant to subsection (d) of this section, and
“(B) will deduct the amount of such reimbursement for payment which would otherwise be made to such organization.”
Subsec. (g)(5). Pub. L. 100–203, § 4013, which directed amendment of par. (5) by substituting “six years” for “four years”, was amended generally by Pub. L. 100–360, § 411(c)(3), so that it does not amend this section.
Subsec. (i)(6). Pub. L. 100–203, § 4014, amended par. (6) generally. Prior to amendment, par. (6) read as follows:
“(6)(A) Any eligible organization with a risk-sharing contract under this section that fails substantially to provide medically necessary items and services that are required (under law or such contract) to be provided to individuals covered under such contract, if the failure has adversely affected (or has a substantial likelihood of adversely affecting) these individuals, is subject to a civil money penalty of not more than $10,000 for each such failure.
“(B) The provisions of section 1320a–7a of this title (other than subsection (a)) shall apply to a civil money penalty under subparagraph (A) in the same manner as they apply to a civil money penalty under that section.”
Subsec. (i)(7)(A). Pub. L. 100–203, § 4039(h)(8)(A), (B), as added by Pub. L. 100–360, § 411(e)(3), substituted “Each” for “Except as provided under section 1320c–3(a)(4)(C) of this title, each”, inserted “or with an entity selected by the Secretary under section 1320c–3(a)(4)(C) of this title” after “located)”, and substituted “which the review organization” for “which the peer review organization”.
Subsec. (i)(7)(B). Pub. L. 100–203, § 4039(h)(8)(C), as added by Pub. L. 100–360, § 411(e)(3), substituted “the review organization” for “the peer review organization”.
1986—Subsec. (a)(1)(A). Pub. L. 99–514 substituted “announce (in a manner intended to provide notice to interested parties)” for “publish” in introductory provisions.
Pub. L. 99–272, § 9211(d), inserted “, and shall publish not later than September 7 before the calendar year concerned” after “The Secretary shall annually determine” in introductory provisions.
Subsec. (a)(3). Pub. L. 99–272, § 9211(a)(2), substituted “Subject to subsection (c)(7), payments” for “Payments”.
Subsec. (a)(6). Pub. L. 99–272, § 9211(a)(3), substituted “Subject to subsection (c)(7), if” for “If”.
Subsec. (c)(3)(B). Pub. L. 99–272, § 9211(b), substituted “the date on which” for “a full calendar month after”, and inserted provision at end that in the case of an individual’s termination of enrollment, the organization shall provide the individual with a copy of the written request for termination of enrollment and a written explanation of the period (ending on the effective date of the termination) during which the individual continues to be enrolled with the organization and may not receive benefits under this subchapter other than through the organization.
Subsec. (c)(3)(C). Pub. L. 99–272, § 9211(c), inserted provisions at end that no brochures, application forms, or other promotional or informational material may be distributed by an organization to (or for the use of) individuals eligible to enroll with the organization under this section unless at least 45 days before its distribution, the organization has submitted the material to the Secretary for review and the Secretary has not disapproved the distribution of the material, and that Secretary shall review all such material submitted and shall disapprove such material if the Secretary determines, in the Secretary’s discretion, that the material is materially inaccurate or misleading or otherwise makes a material misrepresentation.
Subsec. (c)(7). Pub. L. 99–272, § 9211(a)(1), added par. (7).
Subsec. (c)(3)(E). Pub. L. 99–509, § 9312(b)(1), added subpar. (E).
Subsec. (f)(2). Pub. L. 99–509, § 9312(c)(1), struck out “if the Secretary determines that” after “imposed by paragraph (1) only”, added new subpars. (A) and (B), and struck out former subpars. (A) and (B) which read as follows:
“(A) special circumstances warrant such modification or waiver, and
“(B) the eligible organization has taken and is making reasonable efforts to enroll individuals who are not entitled to benefits under this subchapter or under a State plan approved under subchapter XIX of this chapter.”
Subsec. (f)(3). Pub. L. 99–509, § 9312(c)(2)(A), added par. (3).
Subsec. (g)(6). Pub. L. 99–509, § 9312(d)(1), added par. (6).
Subsec. (i)(1)(C). Pub. L. 99–509, § 9312(c)(3)(B), substituted “(e), and (f)” for “and (e)”.
Subsec. (i)(3)(C). Pub. L. 99–509, § 9312(e)(1), designated existing provisions as cl. (i) and added cls. (ii) and (iii).
Subsec. (i)(6). Pub. L. 99–509, § 9312(f), added par. (6).
Subsec. (i)(7). Pub. L. 99–509, § 9353(e)(2), added par. (7).
1984—Subsec. (b)(2)(D). Pub. L. 98–369, § 2354(b)(37), substituted “subparagraph (A)” for “paragraph (1)”.
Subsec. (c)(3)(A). Pub. L. 98–369, § 2350(a)(1), designated existing provisions as cl. (i), inserted “and including the 30-day period specified under clause (ii)” after “30 days duration every year”, and added cl. (ii).
Subsec. (c)(4)(A)(i). Pub. L. 98–369, § 2354(b)(38), substituted “with reasonable promptness” for “promptly as appropriate”.
Subsec. (g)(2). Pub. L. 98–369, § 2350(b)(1), inserted “and except that an organization (with the approval of the Secretary) may provide that a part of the value of such additional benefits be withheld and reserved by the Secretary as provided in paragraph (5)” at end of first sentence.
Subsec. (g)(4)(A). Pub. L. 98–369, § 2350(c), inserted “and skilled nursing facilities” after “hospitals”, inserted “or the appropriate basis for payment established under this subchapter” after “section 1395x(v) of this title)”, and struck out “hospital” before “services furnished to individuals”.
Subsec. (g)(5). Pub. L. 98–369, § 2350(b)(2), added par. (5).
1983—Subsec. (a)(5)(A)(ii). Pub. L. 98–21, § 606(a)(3)(H)(i), substituted “1395r(a)(1)” for “1395r(c)(1)”.
Subsec. (a)(5)(B)(ii). Pub. L. 98–21, § 606(a)(3)(H)(ii), substituted “1395r(a)(4)” for “1395r(c)(4)”.
Subsec. (g)(1). Pub. L. 97–448 substituted “subsection (b)” for “subsection (b)(1)”.
Subsec. (g)(4). Pub. L. 98–21, § 602(g), added par. (4).
1982—Pub. L. 97–248 completely revised section, expanding its coverage to permit payments to both health maintenance organizations and competitive medical plans.
1978—Subsec. (b)(2)(B). Pub. L. 95–292 substituted “Administrator of the Health Care Financing Administration” for “Commissioner of Social Security”.
1976—Subsec. (b). Pub. L. 94–460, § 201(a), struck out provisions defining a health maintenance organization as a public or private organization which provides physicians’ services and a sufficient number of primary care and specialty care physicians, assures its members access to qualified practitioners in specialties available in area served by such organization, demonstrates financial responsibility and means to provide comprehensive health care services, has at least half of its enrolled members under age 65, assures prompt and qualified health service, and has an open enrollment period at least every year, and revised the definition and requirements of an health maintenance organization to conform to those set forth in the Public Health Service Act, except that the services which such an organization must provide are those covered in parts A and B of this subchapter rather than the basic health services defined in the Public Health Service Act, and inserted provisions requiring Secretary to administer determinations of whether an organization is a health maintenance organization through and in the office of the Assistant Secretary for Health, to integrate the administration of such functions and duties with the administration of provisions requiring the continued regulation of health maintenance organizations under the Public Health Service Act, and to administer other provisions of this section through the Commissioner of Social Security.
Subsec. (h). Pub. L. 94–460, § 201(b), substituted provisions that each health maintenance organization with which the Secretary enters into a contract under this section have an enrolled membership at least half of which consists of individuals who have not attained age 65, with the Secretary empowered to waive that requirement for a period of not more than three years from the date a health maintenance organization first enters into an agreement with the Secretary pursuant to subsection (i) of this section for provisions that such requirement not apply with respect to any health maintenance organization for such period not to exceed three years from the date such organization enters into an agreement with the Secretary pursuant to subsection (i) of this section, as the Secretary might permit.
Subsec. (i)(6)(B). Pub. L. 94–460, § 201(c), substituted “(other than costs with respect to out-of-area services and, in the case of an organization which has entered into a risk-sharing contract with the Secretary pursuant to paragraph (2)(A), the cost of providing any member with basic health services the aggregate value of which exceeds $5,000 in any year)” for “(Other than those with respect to out-of-area services)”.
Subsec. (k). Pub. L. 94–460, § 201(d), added subsec. (k).
1973—Subsec. (a)(3)(A)(ii). Pub. L. 93–233, § 18(m), struck out “, with the apportionment of savings being proportional to the losses absorbed and not yet offset” at end.
Subsec. (g)(2). Pub. L. 93–233, § 18(n), substituted “portion of its premium rate or other charges” for “portion” and “shall not exceed” for “may not exceed”, and struck out cl. (i) designation preceding “the actuarial value” and provisions reading “less (ii) the actuarial value of other charges made in lieu of such deductible and coinsurance”, respectively.
1972—Subsec. (i). Pub. L. 92–603, § 278(b)(3), substituted “skilled nursing facility” for “extended care facility” and “skilled nursing facilities” for “extended care facilities”.
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 Pub. L. 108–173, set out as a note under section 1395w–21 of this title.
Amendment by Pub. L. 112–40 applicable to contracts entered into or renewed on or after
Pub. L. 104–191, title II, § 215(c),
Amendment by section 231(g) of Pub. L. 104–191 applicable to acts or omissions occurring on or after
Amendment by Pub. L. 103–432 effective as if included in the enactment of Pub. L. 101–508, see section 157(b)(8) of Pub. L. 103–432, set out as a note under section 1395y of this title.
Amendment by Pub. L. 103–296 effective
Pub. L. 101–508, title IV, § 4204(a)(4),
Pub. L. 101–508, title IV, § 4204(c)(3),
Pub. L. 101–508, title IV, § 4204(d)(2),
Pub. L. 101–508, title IV, § 4204(e)(2),
Amendment by section 4206(b)(1) of Pub. L. 101–508 applicable to contracts under this section and payments under section 1395l(a)(1)(A) of this title as of the first day of the first month beginning more than 1 year after
Pub. L. 101–239, title VI, § 6206(b)(2),
Pub. L. 101–239, title VI, § 6212(b)(2),
Pub. L. 101–239, title VI, § 6212(c)(3),
Pub. L. 101–239, title VI, § 6411(d)(4)(B),
Amendment by section 201(a) of Pub. L. 101–234 effective
Amendment by section 202(a) of Pub. L. 101–234 effective
Pub. L. 100–647, title VIII, § 8412(b),
Amendment by Pub. L. 100–485 effective as if included in the enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L. 100–360, see section 608(g)(1) of Pub. L. 100–485, set out as a note under section 704 of this title.
Amendment by section 202(f) of Pub. L. 100–360 applicable to enrollments effected on or after
Amendment by section 211(c)(3) of Pub. L. 100–360 applicable, except as specified in such amendment, to monthly premiums for months beginning with January 1989, see section 211(d) of Pub. L. 100–360, set out as a note under section 1395r of this title.
Except as specifically provided in section 411 of Pub. L. 100–360, amendment by section 411(c)(1), (3), (4), (6), (e)(3) of Pub. L. 100–360, as it relates to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100–203, effective as if included in the enactment of that provision in Pub. L. 100–203, see section 411(a) of Pub. L. 100–360, set out as a Reference to OBRA; Effective Date note under section 106 of Title 1, General Provisions.
Pub. L. 100–203, title IV, § 4011(a)(2),
Pub. L. 100–203, title IV, § 4011(b)(2),
Pub. L. 100–203, title IV, § 4012(d),
Pub. L. 100–203, title IV, § 4013(b),
Pub. L. 99–514, title XVIII, § 1895(b)(11)(B),
Pub. L. 99–509, title IX, § 9312(b)(2),
Pub. L. 99–509, title IX, § 9312(c)(3), “(A) The amendment made by paragraph (1) [amending this section] shall apply to modifications and waivers granted after the date of the enactment of this Act [“(B) The amendments made by paragraph (2) [amending this section] shall take effect on the date of the enactment of this Act.“(C) In the case of an eligible organization (or successor organization) that—“(i) as of the date of the enactment of this Act, has been granted, under paragraph (2) of section 1876(f) of the Social Security Act [42 U.S.C. 1395mm(f)(2)], a modification or waiver of the requirement imposed by paragraph (1) of that section, but“(ii) does not meet the requirement for such modification or waiver under the amendment made by paragraph (1) of this subsection,the organization shall make, and continue to make, reasonable efforts to meet scheduled enrollment goals, consistent with a schedule of compliance approved by the Secretary of Health and Human Services. If the Secretary determines that the organization has complied, or made significant progress towards compliance, with such schedule of compliance, the Secretary may extend such waiver. If the Secretary determines that the organization has not complied with such schedule, the Secretary may provide for a sanction described in section 1876(f)(3) of the Social Security Act [42 U.S.C. 1395mm(f)(3)] (as amended by this section) effective with respect to individuals enrolling with the organization after the date the Secretary notifies the organization of such noncompliance.“(D) In the case of an eligible organization (or successor organization) that is described in clauses (i) and (ii) of subparagraph (C) and that received a grant or grants totaling at least $3,000,000 in fiscal year 1987 under section 329(d)(1)(A) or 330(d)(1) of the Public Health Service Act [42 U.S.C. 254b(d)(1)(A), 254c(d)(1)]—“(i) before “(ii) beginning on “(iii) after
Pub. L. 99–509, title IX, § 9312(d)(2),
Pub. L. 99–509, title IX, § 9312(e)(2),
Pub. L. 99–509, title IX, § 9353(e)(3)(B),
Pub. L. 99–272, title IX, § 9211(e), “(1) The amendments made by subsection (a) [amending this section] shall apply to enrollments and disenrollments that become effective on or after the date of the enactment of this Act [“(2) The amendments made by subsection (b) [amending this section] shall apply to requests for termination of enrollment submitted on or after “(3) (A) The amendment made by subsection (c) [amending this section] shall not apply to material which has been distributed before “(B) Such amendment also shall not apply so as to require the submission of material which is distributed before “(C) Such amendment shall also not apply to material which the Secretary determines has been prepared before the date of the enactment of this Act [“(4) The amendment made by subsection (d) [amending this section] shall apply to determinations of per capita rates of payment for 1987 and subsequent years.“(5) The Secretary of Health and Human Services shall provide for such changes in the risk-sharing contracts which have been entered into under section 1876 of the Social Security Act [42 U.S.C. 1395mm] as may be necessary to conform to the requirements imposed by the amendments made by this section [amending this section] on a timely basis.”
Pub. L. 98–369, div. B, title III, § 2350(d),
Amendment by section 2354(b)(37), (38) of Pub. L. 98–369 effective
Amendment by section 602(g) of Pub. L. 98–21 applicable to items and services furnished by or under arrangement with a hospital beginning with its first cost reporting period that begins on or after
Amendment by section 606(a)(3)(H) of Pub. L. 98–21 applicable to premiums for months beginning with January 1984, but for months after June 1983 and before January 1984, the monthly premium for June 1983 shall apply to individuals enrolled under parts A and B of this subchapter, see section 606(c) of Pub. L. 98–21, set out as a note under section 1395r of this title.
Amendment by section 309(b)(12) of Pub. L. 97–448 effective as if originally included as a part of this section as this section was amended by the Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97–248, see section 309(c)(2) of Pub. L. 97–448, set out as a note under section 426–1 of this title.
Pub. L. 97–248, title I, § 114(c), “(1) Subject to paragraph (2), the amendment made by subsection (a) [amending this section] shall apply with respect to services furnished on or after the initial effective date (as defined in paragraph (4)), except that such amendment shall not apply—“(A) with respect to services furnished by an eligible organization to any individual who is enrolled with that organization under an existing cost contract (as defined in paragraph (3)(A)) and entitled to benefits under part A [42 U.S.C. 1395c et seq.], or enrolled in part B [42 U.S.C. 1395j et seq.], of title XVIII of the Social Security Act at the time the organization first enters into a new risk-sharing contract (as defined in paragraph (3)(D)) unless—“(i) the individual requests at any time that the amendment apply, or“(ii) the Secretary determines at any time that the amendment should apply to all members of the organization because of administrative costs or other administrative burdens involved and so informs in advance each affected member of the eligible organization;“(B) with respect to services furnished by an eligible organization during the five-year period beginning on the initial effective date, if—“(i) the organization has an existing risk-sharing contract (as defined in paragraph (3)(B)) on the initial effective date, or“(ii) on the date of the enactment of this Act [unless the organization requests that the amendment apply earlier; or“(C) with respect to services furnished by an eligible organization during the period of an existing demonstration project if on the initial effective date the organization was furnishing services pursuant to the project and if the project concludes after such date.“(2)(A) In the case of an eligible organization which has in effect an existing cost contract (as defined in paragraph (3)(A)) on the initial effective date, the organization may receive payment under a new risk-sharing contract with respect to a current, nonrisk medicare enrollee (as defined in subparagraph (C)) only to the extent that the organization enrolls, for each such enrollee, two new medicare enrollees (as defined in subparagraph (D)). The selection of those current nonrisk medicare enrollees with respect to whom payment may be so received under a new risk-sharing contract shall be made in a nonbiased manner.“(B) Subparagraph (A) shall not be construed to prevent an eligible organization from providing for enrollment, on a basis described in subsection (a)(6) of section 1876 of the Social Security Act [42 U.S.C. 1395mm(a)(6)] (as amended by this Act [Pub. L. 97–248], other than under a reasonable cost reimbursement contract), of current, nonrisk medicare enrollees and from providing such enrollees with some or all of the additional benefits described in section 1876(g)(2) of the Social Security Act [42 U.S.C. 1395mm(g)(2)] (as amended by this Act [Pub. L. 97–248]), but (except as provided in subparagraph (A))—“(i) payment to the organization with respect to such enrollees shall only be made in accordance with the terms of a reasonable cost reimbursement contract, and“(ii) no payment may be made under section 1876 of such Act [42 U.S.C. 1395mm] with respect to such enrollees for any such additional benefits.Individuals enrolled with the organization under this subparagraph shall be considered to be individuals enrolled with the organization for the purpose of meeting the requirement of section 1876(g)(2) of the Social Security Act [42 U.S.C. 1395mm(g)(2)] (as amended by this Act [Pub. L. 97–248]).“(C) For purposes of this paragraph, the term ‘current, nonrisk medicare enrollee’ means, with respect to an organization, an individual who on the initial effective date—“(i) is enrolled with that organization under an existing cost contract, and“(ii) is entitled to benefits under part A [42 U.S.C. 1395c et seq.] and enrolled under part B [42 U.S.C. 1395j et seq.], or enrolled in part B, of title XVIII of the Social Security Act.“(D) For purposes of this paragraph, the term ‘new medicare enrollee’ means, with respect to an organization, an individual who—“(i) is enrolled with the organization after the date the organization first enters into a new risk-sharing contract,“(ii) at the time of such enrollment is entitled to benefits under part A, or enrolled in part B, of title XVIII of the Social Security Act, and“(iii) was not enrolled with the organization at the time the individual became entitled to benefits under part A, or to enroll in part B, of such title.“(E) The preceding provisions of this paragraph shall not to [sic] apply to payments made for current, nonrisk medicare enrollees for months beginning with April 1987.“(3) For purposes of this subsection:“(A) The term ‘existing cost contract’ means a contract which is entered into under section 1876 of the Social Security Act [42 U.S.C. 1395mm], as in effect before the initial effective date, or reimbursement on a reasonable cost basis under section 1833(a)(1)(A) of such Act [42 U.S.C. 1395l(a)(1)(A)], and which is not an existing risk-sharing contract or an existing demonstration project.“(B) The term ‘existing risk-sharing contract’ means a contract entered into under section 1876(i)(2)(A) of the Social Security Act [42 U.S.C. 1395mm(i)(2)(A)], as in effect before the initial effective date.“(C) The term ‘existing demonstration project’ means a demonstration project under section 402(a) of the Social Security Amendments of 1967 [42 U.S.C. 1395b–1(a)] or under section 222(a) of the Social Security Amendments of 1972 [section 222(a) of Pub. L. 92–603, set out as a note under section 1395b–1 of this title], relating to the provision of services for which payment may be made under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.].“(D) The term ‘new risk-sharing contract’ means a contract entered into under section 1876(g) of the Social Security Act [42 U.S.C. 1395mm(g)], as amended by this Act [Pub. L. 97–248].“(E) The term ‘reasonable cost reimbursement contract’ means a contract entered into under section 1876(h) of such Act [42 U.S.C. 1395mm(h)], as amended by this Act, or reimbursement on a reasonable cost basis under section 1833(a)(1)(A) of such Act [42 U.S.C. 1395l(a)(1)(A)].“(4) As used in this section, the term ‘initial effective date’ means—“(A) the first day of the thirteenth month which begins after the date of the enactment of this Act [“(B) the first day of the first month [whichever is later.”
Amendment by Pub. L. 95–292 effective with respect to services, supplies, and equipment furnished after the third calendar month beginning after
Pub. L. 94–460, title II, § 201(e),
Pub. L. 93–233, § 18(z–3)(3),
Pub. L. 92–603, title II, § 226(f),
Pub. L. 105–33, title IV, § 4002(b)(2)(B),
Pub. L. 105–33, title IV, § 4002(h),
Pub. L. 101–508, title IV, § 4204(b), “(1)(A) Not later than “(B) In proposing the revisions required under subparagraph (A), the Secretary shall consider—“(i) the difference in costs associated with medicare beneficiaries with differing health status and demographic characteristics; and“(ii) the effects of using alternative geographic classifications on the determinations of costs associated with beneficiaries residing in different areas.“(2) Not later than 3 months after the date of submittal of the proposal under paragraph (1), the Comptroller General shall review the proposal and shall report to Congress on the appropriateness of the proposed modifications.”
[Amendment by section 122(g) of Pub. L. 104–316 to section 4204(b)(4), (5) of Pub. L. 101–508, set out above, could not be executed, because section 4204(b) of Pub. L. 101–508 did not contain pars. (4) and (5) subsequent to amendment by Pub. L. 103–432.]
Pub. L. 101–508, title IV, § 4204(f),
Conscientious objections of health care provider under State law unaffected by enactment of subsec. (c)(8) of this section, see section 4206(c) of Pub. L. 101–508, set out as a note under section 1395cc of this title.
Pub. L. 101–239, title VI, § 6206(a)(2),
Pub. L. 101–234, title II, § 203(b), “(1) with eligible organizations under section 1876 of the Social Security Act [42 U.S.C. 1395mm], or“(2) with health maintenance organizations under section 1876(i)(2)(A) of such Act [42 U.S.C. 1395mm(i)(2)(A)] (as in effect before
Pub. L. 100–360, title II, § 222, “The Secretary of Health and Human Services shall—“(1) modify contracts under section 1876 of the Social Security Act [42 U.S.C. 1395mm], for portions of contract years occurring after “(2) require such organizations and organizations paid under section 1833(a)(1)(A) of such Act [42 U.S.C. 1395l(a)(1)(A)] to make appropriate adjustments (including adjustments in premiums and benefits) in the terms of their agreements with medicare beneficiaries to take into account such amendments.The Secretary shall also provide for appropriate modifications of contracts with health maintenance organizations under section 1876(i)(2)(A) of the Social Security Act [42 U.S.C. 1395mm(i)(2)(A)] (as in effect before
Pub. L. 100–203, title IV, § 4012(c),
Pub. L. 100–203, title IV, § 4015, “(a) “(1) The Secretary of Health and Human Services (in this subsection referred to as the ‘Secretary’) may provide for capitation demonstration projects (in this subsection referred to as ‘projects’) with an entity which is an eligible organization with a contract with the Secretary under section 1876 of the Social Security Act [42 U.S.C. 1395mm] or which meets the restrictions and requirements of this subsection. The Secretary may not approve a project unless it meets the requirements of this subsection.“(2) The Secretary may not conduct more than 3 projects and may not expend, from funds under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], more than $600,000,000 in any fiscal year for all such projects.“(3) The per capita rate of payment under a project—“(A) may be based on the adjusted average per capita cost (as defined in section 1876(a)(4) of the Social Security Act [42 U.S.C. 1395mm(a)(4)]) determined only with respect to the group of individuals involved (rather than with respect to medicare beneficiaries generally), but“(B) the rate of payment may not exceed the lesser of—“(i) 95 percent of the adjusted average per capita cost described in subparagraph (A), or“(ii)(I) in the 4th year or 5th year of a project, 115 percent of the adjusted average per capita cost (as defined in section 1876(a)(4) of such Act [42 U.S.C. 1395mm(a)(4)]) for classes of individuals described in section 1876(a)(1)(B) of that Act [42 U.S.C. 1395mm(a)(1)(B)], or“(II) in any subsequent year of a project, 95 percent of the adjusted average per capita cost (as defined in section 1876(a)(4) [42 U.S.C. 1395mm(a)(4)]) for such classes.“(4) If the payment amounts made to a project are greater than the costs of the project (as determined by the Secretary or, if applicable, on the basis of adjusted community rates described in section 1876(e)(3) of the Social Security Act [42 U.S.C. 1395mm(e)(3)]), the project—“(A) may retain the surplus, but not to exceed 5 percent of the average adjusted per capita cost determined in accordance with paragraph (3)(A), and“(B) with respect to any additional surplus not retained by the project, shall apply such surplus to additional benefits for individuals served by the project or return such surplus to the Secretary.“(5) Enrollment under the project shall be voluntary. Individuals enrolled with the project may terminate such enrollment as of the beginning of the first calendar month following the date on which the request is made for such termination. Upon such termination, such individuals shall retain the same rights to other health benefits that such individuals would have had if they had never enrolled with the project without any exclusion or waiting period for pre-existing conditions.“(6) The requirements of—“(A) subsection (c)(3)(C) (relating to dissemination of information),“(B) subsection (c)(3)(E) (annual statement of rights),“(C) subsection (c)(5) (grievance procedures),“(D) subsection (c)(6) (on-going quality),“(E) subsection (g)(6) (relating to prompt payment of claims),“(F) subsection (i)(3)(A) and (B) (relating to access to information and termination notices),“(G) subsection (i)(6) (relating to providing necessary services), and“(H) subsection (i)(7) (relating to agreements with peer review [now “quality improvement”] organizations),of section 1876 of the Social Security Act [42 U.S.C. 1395mm] shall apply to a project in the same manner as they apply to eligible organizations with risk-sharing contracts under such section.“(7) The benefits provided under a project must be at least actuarially equivalent to the combination of the benefits available under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] and the benefits available through any alternative plans in which the individual can enroll through the employer. The project shall guarantee the actuarial value of benefits available under the employer plan for the duration of the project.“(8) A project shall comply with all applicable State laws.“(9) The Secretary may not authorize a project unless the entity offering the project demonstrates to the satisfaction of the Secretary that it has the necessary financial reserves to pay for any liability for benefits under the project (including those liabilities for health benefits under medicare and any supplemental benefits).“(10) The Comptroller General shall monitor projects under this subsection and shall report periodically (not less often than once every year) to the Committee on Finance of the Senate and the Committee on Energy and Commerce and Committee on Ways and Means of the House of Representatives on the status of such projects and the effect on such projects of the requirements of this section and shall submit a final report to each such committee on the results of such projects.“(b) “(1) The Secretary of Health and Human Services (in this subsection referred to as the ‘Secretary’) is specifically authorized to conduct demonstration projects under this subsection for the purpose of testing alternative payment methodologies pertaining to capitation payments under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], including—“(A) computing adjustments to the average per capita cost under section 1876 of such Act [42 U.S.C. 1395mm] on the basis of health status or prior utilization of services, and“(B) accounting for geographic variations in cost in the adjusted average per capita costs applicable to an eligible organization under such section which differs from payments currently provided on a county-by-county basis.“(2) No project may be conducted under this subsection—“(A) with an entity which is not an eligible organization (as defined in section 1876(b) of the Social Security Act [42 U.S.C. 1395mm(b)]), and“(B) unless the project meets all the requirements of subsections (c) and (i)(3) of section 1876 of such Act [42 U.S.C. 1395mm(c), (i)(3)].“(3) There are authorized to be appropriated to carry out projects under this subsection $5,000,000 in each of fiscal years 1989 and 1990.“(c) The provisions of subsection (a)(2) and the first sentence of subsection (b) of section 402 of the Social Security Amendments of 1967 [42 U.S.C. 1395b–1(a)(2), (b)] shall apply to the demonstration projects under this section in the same manner as they apply to experiments under subsection (a)(1) of that section.”
[For termination, effective
Pub. L. 100–203, title IV, § 4017,
Pub. L. 106–113, div. B, § 1000(a)(6) [title V, § 532], “(a) Notwithstanding any other provision of law, any demonstration project conducted under section 4079 of the Omnibus Budget Reconciliation Act of 1987 (Public Law 100–123 [Pub. L. 100–203]; 42 U.S.C. 1395mm note) and conducted for the additional period of 2 years as provided for under section 4019 of BBA [Pub. L. 105–33, set out as a note below], shall be conducted for an additional period of 2 years.“(b) “(1) For the 9-month period beginning with January 2000, any such demonstration project shall be conducted under the same terms and conditions as applied to such demonstration during 1999.“(2) For the 15-month period beginning with October 2000, any such demonstration project shall be conducted under the same terms and conditions as applied to such demonstration during 1999, except that the following modifications shall apply:“(A) The basic capitation rate paid for services covered under the project (other than case management services) per enrollee per month and furnished during—“(i) the period beginning with “(ii) 2001 shall be determined by actuarially adjusting the capitation rate determined under clause (i) for inflation, utilization, and other changes to the CNO service package.“(B) Effective “(i) the case management fee per enrollee per month for— “(I) the period described in subparagraph (A)(i) shall be determined by actuarially adjusting the case management fee for 1999 for inflation; and “(II) 2001 shall be determined by actuarially adjusting the amount determined under subclause (I) for inflation; and“(ii) such case management fee shall be paid only for enrollees who are classified as moderately frail or frail pursuant to criteria established by the Secretary.“(C) Each project shall implement for each site—“(i) protocols for periodic telephonic contact with enrollees based on— “(I) the results of such standardized written health assessment; and “(II) the application of appropriate care planning approaches;“(ii) disease management programs for targeted diseases (such as congestive heart failure, arthritis, diabetes, and hypertension) that are highly prevalent in the enrolled populations;“(iii) systems and protocols to track enrollees through hospitalizations, including pre-admission planning, concurrent management during inpatient hospital stays, and post-discharge assessment, planning, and follow-up; and“(iv) standardized patient educational materials for specified diseases and health conditions.“(D) Each project shall implement at each site once during the 15-month period—“(i) enrollee satisfaction surveys; and“(ii) reporting on specified quality indicators for the enrolled population.“(c) “(1) Not later than “(A) evaluates such demonstration projects for the period beginning “(B) includes a similar evaluation of such projects for the portion of the extension period that occurs after “(2) The Secretary shall submit a final report to such Committees on such demonstration projects not later than “(3) Any evaluation of the impact of the demonstration projects on per beneficiary spending included in such reports shall include a comparison of—“(A) data for all individuals who—“(i) were enrolled in such demonstration projects as of the first day of the period under evaluation; and“(ii) were enrolled for a minimum of 6 months thereafter; with“(B) data for a matched sample of individuals who are enrolled under part B of title XVIII of the Social Security Act [42 U.S.C. 1395j et seq.] and are not enrolled in such a project, or in a Medicare+Choice plan under part C of such title [42 U.S.C. 1395w–21 et seq.], a plan offered by an eligible organization under section 1876 of such Act [42 U.S.C. 1395mm], or a health care prepayment plan under section 1833(a)(1)(A) of such Act [42 U.S.C. 1395l(a)(1)(A)].”
[Pub. L. 106–554, § 1(a)(6) [title VI, § 632(b)],
Pub. L. 105–33, title IV, § 4019,
Pub. L. 100–203, title IV, § 4079, “(a) The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall enter into an agreement with not less than four eligible organizations submitting applications under this section to conduct demonstration projects to provide payment on a prepaid, capitated basis for community nursing and ambulatory care furnished to any individual entitled to benefits under part A and enrolled under part B of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq., 1395j et seq.] (other than an individual medically determined to have end-stage renal disease) who resides in the geographic area served by the organization and enrolls with such organization (in accordance with subsection (c)(2)).“(b) As used in this section:“(1) The term ‘community nursing and ambulatory care’ means the following services:“(A) Part-time or intermittent nursing care furnished by or under the supervision of registered professional nurses.“(B) Physical, occupational, or speech therapy.“(C) Social and related services supportive of a plan of ambulatory care.“(D) Part-time or intermittent services of a home health aide.“(E) Medical supplies (other than drugs and biologicals) and durable medical equipment while under a plan of care.“(F) Medical and other health services described in paragraphs (2)(H)(ii) and (5) through (9) of section 1861(s) of the Social Security Act [42 U.S.C. 1395x(s)(2)(H)(ii), (5)–(9)].“(G) Rural health clinic services described in section 1861(aa)(1)(C) of such Act [42 U.S.C. 1395x(aa)(1)(C)].“(H) Certain other related services listed in section 1915(c)(4)(B) of such Act [42 U.S.C. 1396n(c)(4)(B)] to the extent the Secretary finds such services are appropriate to prevent the need for institutionalization of a patient.“(2) The term ‘eligible organization’ means a public or private entity, organized under the laws of any State, which meets the following requirements:“(A) The entity (or a division or part of such entity) is primarily engaged in the direct provision of community nursing and ambulatory care.“(B) The entity provides directly, or through arrangements with other qualified personnel, the services described in paragraph (1).“(C) The entity provides that all nursing care (including services of home health aids) is furnished by or under the supervision of a registered nurse.“(D) The entity provides that all services are furnished by qualified staff and are coordinated by a registered professional nurse.“(E) The entity has policies governing the furnishing of community nursing and ambulatory care that are developed by registered professional nurses in cooperation with (as appropriate) other professionals.“(F) The entity maintains clinical records on all patients.“(G) The entity has protocols and procedures to assure, when appropriate, timely referral to or consultation with other health care providers or professionals.“(H) The entity complies with applicable State and local laws governing the provision of community nursing and ambulatory care to patients.“(I) The requirements of subparagraphs (B), (D), and (E) of section 1876(b)(2) of the Social Security Act [42 U.S.C. 1395mm(b)(2)(B), (D), (E)].“(c) “(1) The Secretary may not enter into an agreement with an eligible organization to conduct a demonstration project under this section unless the organization meets the requirements of this subsection and subsection (e) 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 [42 U.S.C. 1395 et seq., 1396 et seq.], community nursing and ambulatory care (as defined in subsection (b)(1)) 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 [42 U.S.C. 1395mm(c)(5)] 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 risk-sharing) that minimize the inappropriate substitution of other services under title XVIII of such Act [42 U.S.C. 1395 et seq.] 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 financial responsibility requirements under the project, any pattern of disproportionate or inappropriate institutionalization) the Secretary shall, after notice, terminate the project.“(d) “(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 manner 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 under part A and enrolled under part B of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq., 1395j et seq.].“(2)(A) Except as provided in paragraph (3), the per capita rate of payment under paragraph (1) shall be determined in accordance with this paragraph.“(B) The Secretary shall define appropriate classes of members, based on age, disability status, and such other factors as the Secretary determines to be appropriate, so as to ensure actuarial equivalence. The Secretary may add to, modify, or substitute for such classes, if such changes will improve the determination of actuarial equivalence.“(C) The per capita rate of payment under paragraph (1) for each such class shall be equal to 95 percent of the adjusted average per capita cost (as defined in subparagraph (D)) for that class.“(D) For purposes of subparagraph (C), the term ‘adjusted average per capita cost’ means the average per capita amount that the Secretary estimates in advance (on the basis of actual experience, or retrospective actuarial equivalent based upon an adequate sample and other information and data, in a geographic area served by an eligible organization or in a similar area, with appropriate adjustments to assure actuarial equivalence) would be payable in any contract year for those services covered under parts A and B of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq., 1395j et seq.] and types of expenses otherwise reimbursable under such parts A and B which are described in subparagraphs (A) through (G) of subsection (b)(1) (including administrative costs incurred by organizations described in sections 1816 and 1842 of such Act [42 U.S.C. 1395h, 1395u]), if the services were to be furnished by other than an eligible organization.“(3) The Secretary shall, in consultation with providers, health policy experts, and consumer groups develop capitation-based reimbursement rates for such classes of individuals entitled to benefits under part A and enrolled under part B of the Social Security Act [probably means parts A and B of title XVIII of that Act, 42 U.S.C. 1395c et seq., 1395j et seq.] as the Secretary shall determine. Such rates shall be applied in determining per capita rates of payment under paragraph (1) with respect to at least one eligible organization conducting a demonstration project under this section.“(4)(A) In the case of an eligible organization conducting a demonstration project under this section, the Secretary shall make monthly payments in advance and in accordance with the rate determined under paragraph (2) or (3), except as provided in subsection (e)(3)(B), to the organization for each individual enrolled with the organization.“(B) The amount of payment under paragraph (2) or (3) may be retroactively adjusted to take into account any difference between the actual number of individuals enrolled in the plan under this section and the number of such individuals estimated to be so enrolled in determining the amount of the advance payment.“(5) The payment to an eligible organization under this section for individuals enrolled under this section with the organization and entitled to benefits under part A and enrolled under part B of the Social Security Act shall be made from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund established under such Act [42 U.S.C. 301 et seq.] in such proportions from each such trust fund as the Secretary deems to be fair and equitable taking into consideration benefits attributable to such parts A and B, respectively.“(6) During any period in which an individual is enrolled with an eligible organization conducting a demonstration project under this section, only the eligible organization (and no other individual or person) shall be entitled to receive payments from the Secretary under this title [probably means title XVIII of the Social Security Act, 42 U.S.C. 1395 et seq.] for community nursing and ambulatory care (as defined in subsection (b)(1)) furnished to the individual.“(e) “(1) In no case may the portion of an eligible organization’s premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with respect to community nursing and ambulatory care) to individuals who are enrolled under this section with the organization, exceed the actuarial value of the coinsurance and deductibles that would be applicable on the average to individuals enrolled under this section with the organization (or, if the Secretary finds that adequate data are not available to determine that actuarial value, the actuarial value of the coinsurance and deductibles applicable on the average to individuals in the area, in the State, or in the United States, eligible to enroll under this section with the organization, or other appropriate data) and entitled to benefits under part A and enrolled under part B of the Social Security Act [probably means parts A and B of title XVIII of that Act, 42 U.S.C. 1395c et seq., 1395j et seq.], if they were not members of an eligible organization.“(2) If the eligible organization provides to its members enrolled under this section services in addition to community nursing and ambulatory care, election of coverage for such additional services shall be optional for such members and such organization shall furnish such members with information on the portion of its premium rate or other charges applicable to such additional services. In no case may the sum of—“(A) the portion of such organization’s premium rate charged, with respect to such additional services, to members enrolled under this section, and“(B) the actuarial value of its deductibles, coinsurance, and copayments charged, with respect to such services to such membersexceed the adjusted community rate for such services (as defined in section 1876(e)(3) of the Social Security Act [42 U.S.C. 1395mm(e)(3)]).“(3)(A) Subject to subparagraphs (B) and (C), each agreement to conduct a demonstration project under this section shall provide that if—“(i) the adjusted community rate, referred to in paragraph (2), for community nursing and ambulatory care covered under parts A and B of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq., 1395j et seq.] (as reduced for the actuarial value of the coinsurance and deductibles under those parts) for members enrolled under this section with the organization,is less than“(ii) the average of the per capita rates of payment to be made under subsection (d)(1) at the beginning of the 12-month period (as determined on such basis as the Secretary determines appropriate) described in such subsection for members enrolled under this section with the organization,the eligible organization shall provide to such members the additional benefits described in section 1876(g)(3) of the Social Security Act [42 U.S.C. 1395mm(g)(3)] which are selected by the eligible organization and which the Secretary finds are at least equal in value to the difference between that average per capita payment and the adjusted community rate (as so reduced).“(B) Subparagraph (A) shall not apply with respect to any organization which elects to receive a lesser payment to the extent that there is no longer a difference between the average per capita payment and adjusted community rate (as so reduced).“(C) An organization conducting a demonstration project under this section may provide (with the approval of the Secretary) that a part of the value of such additional benefits under subparagraph (A) be withheld and reserved by the Secretary as provided in section 1876(g)(5) of the Social Security Act [42 U.S.C. 1395mm(g)(5)].“(4) The provisions of paragraphs (3), (5), and (6) of section 1876(g) of the Social Security Act [42 U.S.C. 1395mm(g)(3), (5), (6)] shall apply in the same manner to agreements under this section as they apply to risk-sharing contracts under section 1876 of such Act, and, for this purpose, any reference in such paragraphs to paragraph (2) is deemed a reference to paragraph (3) of this subsection.“(5) Section 1876(e)(4) of the Social Security Act [42 U.S.C. 1395mm(e)(4)] shall apply to eligible organizations under this section in the same manner as it applies to eligible organizations under section 1876 of such Act.“(f) Each demonstration project under this section shall begin not later than “(g) Not later than
Pub. L. 99–509, title IX, § 9312(g),
Pub. L. 99–509, title IX, § 9312(h),
Pub. L. 99–509, title IX, § 9312(i),
Pub. L. 98–369, div. B, title III, § 2350(a)(2),
Pub. L. 98–369, div. B, title III, § 2350(b)(3), (4),
Pub. L. 97–248, title I, § 114(d),
Pub. L. 97–248, title I, § 114(e),
Pub. L. 92–603, title II, § 226(b), “(1) Notwithstanding the provisions of section 1814 and section 1833 of the Social Security Act [42 U.S.C. 1395f, 1395l], any health maintenance organization which has entered into a contract with the Secretary pursuant to section 1876 of such Act [42 U.S.C. 1395mm] shall, for the duration of such contract, (except as provided in paragraph (2)) be entitled to reimbursement only as provided in section 1876 of such Act [42 U.S.C. 1395mm] for individuals who are members of such organizations.“(2) With respect to individuals who are members of organizations which have entered into a risk-sharing contract with the Secretary pursuant to subsection (i)(2)(A) [of this section] prior to “(3) If the Secretary determines that the per capita cost of any such organization in any contract year for providing services to individuals described in paragraph (2), when combined with the cost of the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund in such year for providing out-of-plan services to such individuals, is less than or greater than the adjusted average per capita cost (as defined in section 1876(a)(3) of such Act [42 U.S.C. 1395mm(a)(3)]) of providing such services, the resulting savings shall be apportioned between such organization and such Trust Funds, or the resulting losses shall be absorbed by such organization, in the manner prescribed in section 1876(a)(3) of such Act [42 U.S.C. 1395mm(a)(3)].”