42 USC 1395w-27a - Special rules for MA regional plans

U.S Code last checked for updates: Apr 28, 2024

§ 1395w–27a.

Special rules for MA regional plans

(a)

Regional service area; establishment of MA regions

(1)

Coverage of entire MA region

(2)

Establishment of MA regions

(A)

MA region

(B)

Establishment

(i)

Initial establishment

(ii)

Periodic review and revision of service areas

(C)

Requirements for MA regions

The Secretary shall establish, and may revise, MA regions under this paragraph in a manner consistent with the following:

(i)

Number of regions

(ii)

Maximizing availability of plans

(D)

Market survey and analysis

(3)

National plan

(b)

Application of single deductible and catastrophic limit on out-of-pocket expenses

An MA regional plan shall include the following:

(1)

Single deductible

(2)

Catastrophic limit

(A)

In-network

(B)

Total

(c)

Portion of total payments to an organization subject to risk for 2006 and 2007

(1)

Application of risk corridors

(A)

In general

(B)

Notification of allowable costs under the plan

In the case of an MA organization that offers an MA regional plan in an MA region in 2006 or 2007, the organization shall notify the Secretary, before such date in the succeeding year as the Secretary specifies, of—

(i)

its total amount of costs that the organization incurred in providing benefits covered under the original medicare fee-for-service program option for all enrollees under the plan in the region in the year and the portion of such costs that is attributable to administrative expenses described in subparagraph (C); and

(ii)

its total amount of costs that the organization incurred in providing rebatable integrated benefits (as defined in subparagraph (D)) and with respect to such benefits the portion of such costs that is attributable to administrative expenses described in subparagraph (C) and not described in clause (i) of this subparagraph.

(C)

Allowable costs defined

(D)

Rebatable integrated benefits

(2)

Adjustment of payment

(A)

No adjustment if allowable costs within 3 percent of target amount

(B)

Increase in payment if allowable costs above 103 percent of target amount

(i)

Costs between 103 and 108 percent of target amount

(ii)

Costs above 108 percent of target amount

If the allowable costs for the plan for the year are greater than 108 percent of the target amount for the plan and year, the Secretary shall increase the total of the monthly payments made to the organization offering the plan for the year under section 1395w–23(a) of this title by an amount equal to the sum of—

(I)

2.5 percent of such target amount; and

(II)

80 percent of the difference between such allowable costs and 108 percent of such target amount.

(C)

Reduction in payment if allowable costs below 97 percent of target amount

(i)

Costs between 92 and 97 percent of target amount

(ii)

Costs below 92 percent of target amount

If the allowable costs for the plan for the year are less than 92 percent of the target amount for the plan and year, the Secretary shall reduce the total of the monthly payments made to the organization offering the plan for the year under section 1395w–23(a) of this title by an amount (or otherwise recover from the plan an amount) equal to the sum of—

(I)

2.5 percent of such target amount; and

(II)

80 percent of the difference between 92 percent of such target amount and such allowable costs.

(D)

Target amount described

For purposes of this paragraph, the term “target amount” means, with respect to an MA regional plan offered by an organization in a year, an amount equal to—

(i)

the sum of—

(I)

the total monthly payments made to the organization for enrollees in the plan for the year that are attributable to benefits under the original medicare fee-for-service program option (as defined in section 1395w–22(a)(1)(B) of this title);

(II)

the total of the MA monthly basic beneficiary premium collectable for such enrollees for the year; and

(III)

the total amount of the rebates under section 1395w–24(b)(1)(C)(ii) of this title that are attributable to rebatable integrated benefits; reduced by

(ii)

the amount of administrative expenses assumed in the bid insofar as the bid is attributable to benefits described in clause (i)(I) or (i)(III).

(3)

Disclosure of information

(A)

In general

Each contract under this part shall provide—

(i)

that an MA organization offering an MA regional plan shall provide the Secretary with such information as the Secretary determines is necessary to carry out this subsection; and

(ii)

that, pursuant to section 1395w–27(d)(2)(B) of this title, the Secretary has the right to inspect and audit any books and records of the organization that pertain to the information regarding costs provided to the Secretary under paragraph (1)(B).

(B)

Restriction on use of information

(d)

Organizational and financial requirements

(1)

In general

In the case of an MA organization that is offering an MA regional plan in an MA region and—

(A)

meets the requirements of section 1395w–25(a)(1) of this title with respect to at least one such State in such region; and

(B)

with respect to each other State in such region in which it does not meet requirements, it demonstrates to the satisfaction of the Secretary that it has filed the necessary application to meet such requirements,

the Secretary may waive such requirement with respect to each State described in subparagraph (B) for such period of time as the Secretary determines appropriate for the timely processing of such an application by the State (and, if such application is denied, through the end of such plan year as the Secretary determines appropriate to provide for a transition).

(2)

Selection of appropriate State

(e)

Repealed. Pub. L. 111–148, title X, § 10327(c)(1), Mar. 23, 2010, 124 Stat. 964

(f)

Computation of applicable MA region-specific non-drug monthly benchmark amounts

(1)

Computation for regions

(2)

2 components

For purposes of paragraph (1), the 2 components described in this paragraph for an MA region and a year are the following:

(A)

Statutory component

The product of the following:

(i)

Statutory region-specific non-drug amount

(ii)

Statutory national market share

(B)

Plan-bid component

The product of the following:

(i)

Weighted average of MA plan bids in region

(ii)

Non-statutory market share

(3)

Statutory region-specific non-drug amount

For purposes of paragraph (2)(A)(i), the term “statutory region-specific non-drug amount” means, for an MA region and year, an amount equal the sum (for each MA local area within the region) of the product of—

(A)

MA area-specific non-drug monthly benchmark amount under section 1395w–23(j)(1)(A) of this title for that area and year; and

(B)

the number of MA eligible individuals residing in the local area, divided by the total number of MA eligible individuals residing in the region.

(4)

Computation of statutory market share percentage

(A)

In general

(B)

Reference month defined

(5)

Determination of weighted average MA bids for a region

(A)

In general

For purposes of paragraph (2)(B)(i), the weighted average of plan bids for an MA region and a year is the sum, for MA regional plans described in subparagraph (D) in the region and year, of the products (for each such plan) of the following:

(i)

Monthly MA statutory non-drug bid amount

(ii)

Plan’s share of MA enrollment in region

(B)

Plan’s share of MA enrollment in region

(i)

In general

(ii)

Single plan rule

(iii)

Equal division among multiple plans in year in which plans are first available

In the case of an MA region in the first year in which any MA regional plan is offered, if more than one MA regional plan is offered in such year, the factor described in this subparagraph for a plan shall (as specified by the Secretary) be equal to—

(I)

1 divided by the number of such plans offered in such year; or

(II)

a factor for such plan that is based upon the organization’s estimate of projected enrollment, as reviewed and adjusted by the Secretary to ensure reasonableness and as is certified by the Chief Actuary of the Centers for Medicare & Medicaid Services.

(C)

Counting of individuals

(D)

Plans covered

(g)

Election of uniform coverage determination

(h)

Assuring network adequacy

(1)

In general

For purposes of enabling MA organizations that offer MA regional plans to meet applicable provider access requirements under section 1395w–22 of this title with respect to such plans, the Secretary may provide for payment under this section to an essential hospital that provides inpatient hospital services to enrollees in such a plan where the MA organization offering the plan certifies to the Secretary that the organization was unable to reach an agreement between the hospital and the organization regarding provision of such services under the plan. Such payment shall be available only if—

(A)

the organization provides assurances satisfactory to the Secretary that the organization will make payment to the hospital for inpatient hospital services of an amount that is not less than the amount that would be payable to the hospital under section 1395ww of this title with respect to such services; and

(B)

with respect to specific inpatient hospital services provided to an enrollee, the hospital demonstrates to the satisfaction of the Secretary that the hospital’s costs of such services exceed the payment amount described in subparagraph (A).

(2)

Payment amounts

The payment amount under this subsection for inpatient hospital services provided by a subsection (d) hospital to an enrollee in an MA regional plan shall be, subject to the limitation of funds under paragraph (3), the amount (if any) by which—

(A)

the amount of payment that would have been paid for such services under this subchapter if the enrollees were covered under the original medicare fee-for-service program option and the hospital were a critical access hospital; exceeds

(B)

the amount of payment made for such services under paragraph (1)(A).

(3)

Available amounts

There shall be available for payments under this subsection—

(A)

in 2006, $25,000,000; and

(B)

in each succeeding year the amount specified in this paragraph for the preceding year increased by the market basket percentage increase (as defined in section 1395ww(b)(3)(B)(iii) of this title) for the fiscal year ending in such succeeding year.

Payments under this subsection shall be made from the Federal Hospital Insurance Trust Fund.

(4)

Essential hospital

(Aug. 14, 1935, ch. 531, title XVIII, § 1858, as added Pub. L. 108–173, title II, § 221(c), Dec. 8, 2003, 117 Stat. 2181; amended Pub. L. 109–432, div. B, title III, § 301, Dec. 20, 2006, 120 Stat. 2990; Pub. L. 110–48, § 3, July 18, 2007, 121 Stat. 244; Pub. L. 110–173, title I, § 110, Dec. 29, 2007, 121 Stat. 2497; Pub. L. 110–275, title I, § 166, July 15, 2008, 122 Stat. 2575; Pub. L. 111–8, div. G, title I, § 1301(f), Mar. 11, 2009, 123 Stat. 829; Pub. L. 111–148, title III, § 3201(a)(2)(C), (f)(2), title X, § 10327(c)(1), Mar. 23, 2010, 124 Stat. 444, 450, 964; Pub. L. 111–152, title I, § 1102(a), Mar. 30, 2010, 124 Stat. 1040.)

cite as: 42 USC 1395w-27a