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H.R.5661
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act
of 2000 (Introduced in the House)
SEC. 603. PHASE-IN OF RISK
ADJUSTMENT .
Section 1853(a)(3)(C) (42 U.S.C. 1395w-23(a)(3)(C)) is amended--
(A) in subclause (I), by striking `and 2001' and inserting `and each
succeeding year through 2003' and by striking `and' at the end;
and
(B) by striking subclause (II) and inserting the following new
subclauses:
`(II) 30 percent of such capitation rate in 2004;
`(III) 50 percent of such capitation rate in 2005;
`(IV) 75 percent of such capitation rate in 2006;
and
`(V) 100 percent of such capitation rate in 2007 and succeeding
years.'; and
(2) by adding at the end the following new clause:
`(iii) DATA FOR RISK
ADJUSTMENT METHODOLOGY-
Such risk adjustment methodology for 2004
and each succeeding year, shall be based on data from inpatient hospital
and ambulatory settings.'.
SEC. 604. TRANSITION TO REVISED MEDICARE+CHOICE PAYMENT RATES.
(a) ANNOUNCEMENT OF REVISED MEDICARE+CHOICE PAYMENT RATES- Within 2 weeks
after the date of the enactment of this Act, the Secretary of Health and Human
Services shall determine, and shall announce (in a manner intended to provide
notice to interested parties) Medicare+Choice capitation rates under section
1853 of the Social Security Act (42 U.S.C. 1395w-23) for 2001, revised in
accordance with the provisions of this Act.
(b) REENTRY INTO PROGRAM PERMITTED FOR MEDICARE+CHOICE PROGRAMS- A
Medicare+Choice organization that provided notice to the Secretary of Health
and Human Services before the date of the enactment of this Act that it was
terminating its contract under part C of title XVIII of the Social Security
Act or was reducing the service area of a Medicare+Choice plan offered under
such part shall be permitted to continue participation under such part, or to
maintain the service area of such plan, for 2001 if it submits the Secretary
with the information described in section 1854(a)(1) of the Social Security
Act (42 U.S.C. 1395w-24(a)(1)) within 2 weeks after the date revised rates are
announced by the Secretary under subsection (a).
(c) REVISED SUBMISSION OF PROPOSED PREMIUMS AND RELATED INFORMATION-
If--
(1) a Medicare+Choice organization provided notice to the Secretary of
Health and Human Services as of July 3, 2000, that it was renewing its
contract under part C of title XVIII of the Social Security Act for all or
part of the service area or areas served under its current contract,
and
(2) any part of the service area or areas addressed in such notice
includes a payment area for which the Medicare+Choice capitation rate under
section 1853(c) of such Act (42 U.S.C. 1395w-23(c)) for 2001, as determined
under subsection (a), is higher than the rate previously determined for such
year,
such organization shall revise its submission of the information described
in section 1854(a)(1) of the Social Security Act (42 U.S.C. 1395w-24(a)(1)),
and shall submit such revised information to the Secretary, within 2 weeks
after the date revised rates are announced by the Secretary under subsection
(a). In making such submission, the organization may only reduce beneficiary
premiums, reduce beneficiary cost-sharing, enhance benefits, utilize the
stabilization fund described in section 1854(f)(2) of such Act (42 U.S.C.
1395w-24(f)(2)), or stabilize or enhance beneficiary access to providers (so
long as such stabilization or enhancement does not result in increased
beneficiary premiums, increased beneficiary cost-sharing, or reduced
benefits).
(d) WAIVER OF LIMITS ON STABILIZATION FUND- Any regulatory provision that
limits the proportion of the excess amount that can be withheld in such
stabilization fund for a contract period shall not apply with respect to
submissions described in subsections (b) and (c).
(e) DISREGARD OF NEW RATE ANNOUNCEMENT IN APPLYING PASS-THROUGH FOR NEW
NATIONAL COVERAGE DETERMINATIONS- For purposes of applying section 1852(a)(5)
of the Social Security Act (42 U.S.C. 1395w-22(a)(5)), the announcement of
revised rates under subsection (a) shall not be treated as an announcement
under section 1853(b) of such Act (42 U.S.C. 1395w-23(b)).
SEC. 605. REVISION OF PAYMENT RATES FOR ESRD PATIENTS ENROLLED IN
MEDICARE+CHOICE PLANS.
(a) IN GENERAL- Section 1853(a)(1)(B) (42 U.S.C. 1395w-23(a)(1)(B)) is
amended by adding at the end the following: `In establishing such rates, the
Secretary shall provide for appropriate adjustments to increase each rate to
reflect the demonstration rate (including the risk adjustment methodology associated with
such rate) of the social health maintenance organization end-stage renal
disease capitation demonstrations (established by section 2355 of the Deficit
Reduction Act of 1984, as amended by section 13567(b) of the Omnibus Budget
Reconciliation Act of 1993), and shall compute such rates by taking into
account such factors as renal treatment modality, age, and the underlying
cause of the end-stage renal disease.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply to
payments for months beginning with January 2002.
(c) PUBLICATION- Not later than 6 months after the date of the enactment
of this Act, the Secretary of Health and Human Services shall publish for
public comment a description of the appropriate adjustments described in the
last sentence of section 1853(a)(1)(B) of the Social Security Act (42 U.S.C.
1395w-23(a)(1)(B)), as added by subsection (a). The Secretary shall publish
such adjustments in final form by not later than July 1, 2001, so that the
amendment made by subsection (a) is implemented on a timely basis consistent
with subsection (b).
SEC. 606. PERMITTING PREMIUM REDUCTIONS AS ADDITIONAL BENEFITS UNDER
MEDICARE+CHOICE PLANS.
(1) AUTHORIZATION OF PART B PREMIUM REDUCTIONS- Section 1854(f)(1) (42
U.S.C. 1395w-24(f)(1)) is amended--
(A) by redesignating subparagraph (E) as subparagraph (F);
and
(B) by inserting after subparagraph (D) the following new
subparagraph:
`(i) IN GENERAL- Subject to clause (ii), as part of providing any
additional benefits required under subparagraph (A), a Medicare+Choice
organization may elect a reduction in its payments under section
1853(a)(1)(A) with respect to a Medicare+Choice plan and the Secretary
shall apply such reduction to reduce the premium under section 1839 of
each enrollee in such plan as provided in section 1840(i).
`(ii) AMOUNT OF REDUCTION- The amount of the reduction under clause
(i) with respect to any enrollee in a Medicare+Choice plan--
`(I) may not exceed 125 percent of the premium described under
section 1839(a)(3); and
`(II) shall apply uniformly to each enrollee of the
Medicare+Choice plan to which such reduction applies.'.
(2) CONFORMING AMENDMENTS-
(A) ADJUSTMENT OF
PAYMENTS TO MEDICARE+CHOICE ORGANIZATIONS- Section 1853(a)(1)(A) (42
U.S.C. 1395w-23(a)(1)(A)) is amended by inserting `reduced by the amount
of any reduction elected under section 1854(f)(1)(E) and' after `for that
area,'.
(B) ADJUSTMENT AND
PAYMENT OF PART B PREMIUMS-
(i) ADJUSTMENT OF
PREMIUMS- Section 1839(a)(2) (42 U.S.C. 1395r(a)(2)) is amended by
striking `shall' and all that follows and inserting the following:
`shall be the amount determined under paragraph (3), adjusted as
required in accordance with subsections (b), (c), and (f), and to
reflect 80 percent of any reduction elected under section
1854(f)(1)(E).'.
(ii) PAYMENT OF PREMIUMS- Section 1840 (42 U.S.C. 1395s) is amended
by adding at the end the following new subsection:
`(i) In the case of an individual enrolled in a Medicare+Choice plan, the
Secretary shall provide for necessary adjustments of the monthly beneficiary
premium to reflect 80 percent of any reduction elected under section
1854(f)(1)(E). To the extent to which the Secretary determines that such an
adjustment is appropriate, with
the concurrence of any agency responsible for the administration of such
benefits, such premium adjustment may be provided directly,
as an adjustment to any social
security, railroad retirement, or civil service retirement benefits, or, in
the case of an individual who receives medical assistance under title XIX for
medicare costs described in section 1905(p)(3)(A)(ii), as an adjustment to the amount otherwise
owed by the State for such medical assistance.'.
(C) INFORMATION COMPARING PLAN PREMIUMS UNDER PART C- Section
1851(d)(4)(B) (42 U.S.C. 1395w-21(d)(4)(B)) is amended--
(i) by striking `PREMIUMS- The' and inserting `PREMIUMS-
`(i) IN GENERAL- The'; and
(ii) by adding at the end the following new clause:
`(ii) REDUCTIONS- The reduction in part B premiums, if
any.'.
(D) TREATMENT OF REDUCTION FOR PURPOSES OF DETERMINING GOVERNMENT
CONTRIBUTION UNDER PART B- Section 1844 (42 U.S.C. 1395w) is amended by
adding at the end the following new subsection:
`(c) The Secretary shall determine the Government contribution under
subparagraphs (A) and (B) of subsection (a)(1) without regard to any premium
reduction resulting from an election under section 1854(f)(1)(E).'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply to
years beginning with 2003.
SEC. 607. FULL IMPLEMENTATION OF RISK ADJUSTMENT FOR CONGESTIVE HEART FAILURE
ENROLLEES FOR 2001.
(a) IN GENERAL- Section 1853(a)(3)(C) (42 U.S.C. 1395w-23(a)(3)(C)) is
amended--
(1) in clause (ii), by striking `Such risk adjustment' and inserting `Except as
provided in clause (iii), such risk adjustment' ; and
(2) by adding at the end the following new clause:
`(iii) FULL IMPLEMENTATION OF RISK ADJUSTMENT FOR CONGESTIVE HEART
FAILURE ENROLLEES FOR 2001-
`(I) EXEMPTION FROM PHASE-IN- Subject to subclause (II), the
Secretary shall fully implement the risk adjustment methodology
described in clause (i) with respect to each individual who has had a
qualifying congestive heart failure inpatient diagnosis (as determined
by the Secretary under such risk adjustment methodology) during
the period beginning on July 1, 1999, and ending on June 30, 2000, and
who is enrolled in a coordinated care plan that is the only
coordinated care plan offered on January 1, 2001, in the service area
of the individual.
`(II) PERIOD OF APPLICATION- Subclause (I) shall only apply during
the 1-year period beginning on January 1, 2001.'.
(b) EXCLUSION FROM DETERMINATION OF THE BUDGET NEUTRALITY FACTOR- Section
1853(c)(5) (42 U.S.C. 1395w-23(c)(5)) is amended by striking `subsection (i)'
and inserting `subsections (a)(3)(C)(iii) and (i)'.
SEC. 608. EXPANSION OF APPLICATION OF MEDICARE+CHOICE NEW ENTRY BONUS.
(a) IN GENERAL- Section 1853(i)(1) (42 U.S.C. 1395w-23(i)(1)) is amended
in the matter preceding subparagraph (A) by inserting `, or filed notice with
the Secretary as of October 3, 2000, that they will not be offering such a
plan as of January 1, 2001' after `January 1, 2000'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply as if
included in the enactment of BBRA.
SEC. 609. REPORT ON INCLUSION OF CERTAIN COSTS OF THE DEPARTMENT OF VETERANS
AFFAIRS AND MILITARY FACILITY SERVICES IN CALCULATING MEDICARE+CHOICE PAYMENT
RATES.
The Secretary of Health and Human Services shall report to Congress by not
later than January 1, 2003, on a method to phase-in the costs of military
facility services furnished by the Department of Veterans Affairs, and the
costs of military facility services furnished by the Department of Defense, to
medicare-eligible beneficiaries in the calculation of an area's
Medicare+Choice capitation payment. Such report shall include on a
county-by-county basis--
(1) the actual or estimated cost of such services to medicare-eligible
beneficiaries;
(2) the change in Medicare+Choice capitation payment rates if such costs
are included in the calculation of payment rates;
(3) one or more proposals for the implementation of payment adjustments
to Medicare+Choice plans in counties where the payment rate has been
affected due to the failure to calculate the cost of such services to
medicare-eligible beneficiaries; and
(4) a system to ensure that when a Medicare+Choice enrollee receives
covered services through a facility of the Department of Veterans Affairs or
the Department of Defense there is an appropriate payment recovery to the
medicare program under title XVIII of the Social Security Act.
Subtitle B--Other Medicare+Choice Reforms
SEC. 611. PAYMENT OF ADDITIONAL AMOUNTS FOR NEW BENEFITS COVERED DURING A
CONTRACT TERM.
(a) IN GENERAL- Section 1853(c)(7) (42 U.S.C. 1395w-23(c)(7)) is amended
to read as follows:
`(7) ADJUSTMENT FOR
NATIONAL COVERAGE DETERMINATIONS AND LEGISLATIVE CHANGES IN BENEFITS- If the
Secretary makes a determination with respect to coverage under this title or
there is a change in benefits required to be provided under this part that
the Secretary projects will result in a significant increase in the costs to
Medicare+Choice of providing benefits under contracts under this part (for
periods after any period described in section 1852(a)(5)), the Secretary
shall adjust appropriately the payments to such organizations under this
part. Such projection and adjustment shall be based on an
analysis by the Chief Actuary of the Health Care Financing Administration of
the actuarial costs associated with the new benefits.'.
(b) CONFORMING AMENDMENT- Section 1852(a)(5) (42 U.S.C. 1395w-22(a)(5)) is
amended--
(1) in the heading, by inserting `AND LEGISLATIVE CHANGES IN BENEFITS'
after `NATIONAL COVERAGE DETERMINATIONS';
(2) by inserting `or legislative change in benefits required to be
provided under this part' after `national coverage determination';
(3) in subparagraph (A), by inserting `or legislative change in
benefits' after `such determination';
(4) in subparagraph (B), by inserting `or legislative change' after `if
such coverage determination'; and
(5) by adding at the end the following:
`The projection under the previous sentence shall be based on an
analysis by the Chief Actuary of the Health Care Financing Administration of
the actuarial costs associated with the coverage determination or
legislative change in benefits.'.
(c) EFFECTIVE DATE- The amendments made by this section are effective on
the date of the enactment of this Act and shall apply to national coverage
determinations and legislative changes in benefits occurring on or after such
date.
SEC. 612. RESTRICTION ON IMPLEMENTATION OF SIGNIFICANT NEW REGULATORY
REQUIREMENTS MIDYEAR.
(a) IN GENERAL- Section 1856(b) (42 U.S.C. 1395w-26(b)) is amended by
adding at the end the following new paragraph:
`(4) PROHIBITION OF MIDYEAR IMPLEMENTATION OF SIGNIFICANT NEW REGULATORY
REQUIREMENTS- The Secretary may not implement, other than at the beginning
of a calendar year, regulations under this section that impose new,
significant regulatory requirements on a Medicare+Choice organization or
plan.'.
(b) EFFECTIVE DATE- The amendment made by subsection (a) takes effect on
the date of the enactment of this Act.
SEC. 613. TIMELY APPROVAL OF MARKETING MATERIAL THAT FOLLOWS MODEL MARKETING
LANGUAGE.
(a) IN GENERAL- Section 1851(h) (42 U.S.C. 1395w-21(h)) is amended--
(1) in paragraph (1)(A), by inserting `(or 10 days in the case described
in paragraph (5))' after `45 days'; and
(2) by adding at the end the following new paragraph:
`(5) SPECIAL TREATMENT OF MARKETING MATERIAL FOLLOWING MODEL MARKETING
LANGUAGE- In the case of marketing material of an organization that uses,
without modification, proposed model language specified by the Secretary,
the period specified in paragraph (1)(A) shall be reduced from 45 days to 10
days.'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply to
marketing material submitted on or after January 1, 2001.
SEC. 614. AVOIDING DUPLICATIVE REGULATION.
(a) IN GENERAL- Section 1856(b)(3)(B) (42 U.S.C. 1395w-26(b)(3)(B)) is
amended--
(1) in clause (i), by inserting `(including cost-sharing requirements)'
after `Benefit requirements'; and
(2) by adding at the end the following new clause:
`(iv) Requirements relating to marketing materials and summaries and
schedules of benefits regarding a Medicare+Choice plan.'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) take effect on
the date of the enactment of this Act.
SEC. 615. ELECTION OF UNIFORM LOCAL COVERAGE POLICY FOR MEDICARE+CHOICE PLAN
COVERING MULTIPLE LOCALITIES.
Section 1852(a)(2) (42 U.S.C. 1395w-22(a)(2)) is amended by adding at the
end the following new subparagraph:
`(C) ELECTION OF UNIFORM COVERAGE POLICY- In the case of a
Medicare+Choice organization that offers a Medicare+Choice plan in an area
in which more than one local coverage policy is applied with respect to
different parts of the area, the organization may elect to have the local
coverage policy for the part of the area that is most beneficial to
Medicare+Choice enrollees (as identified by the Secretary) apply with
respect to all Medicare+Choice enrollees enrolled in the plan.'.
SEC. 616. ELIMINATING HEALTH DISPARITIES IN MEDICARE+CHOICE PROGRAM.
(a) QUALITY ASSURANCE PROGRAM FOCUS ON RACIAL AND ETHNIC MINORITIES-
Subparagraphs (A) and (B) of section 1852(e)(2) (42 U.S.C. 1395w-22(e)(2)) are
each amended by adding at the end the following:
`Such program shall include a separate focus (with respect to all the
elements described in this subparagraph) on racial and ethnic
minorities.'.
(b) REPORT- Section 1852(e) (42 U.S.C. 1395w-22(e)) is amended by adding
at the end the following new paragraph:
`(A) IN GENERAL- Not later than 2 years after the date of the
enactment of this paragraph, and biennially thereafter, the Secretary
shall submit to Congress a report regarding how quality assurance programs
conducted under this subsection focus on racial and ethnic
minorities.
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