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S.3165
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 2000
(Introduced in the Senate)
SEC. 606. 10-YEAR PHASE-IN OF RISK ADJUSTMENT AND NEW METHODOLOGY.
Section 1853(a)(3)(C)(ii) (42 U.S.C. 1395w-23(c)(1)(C)(ii)) is
amended--
(1) in subclause (I), by striking `and' at the end;
(2) in subclause (II), by striking `2002.' and inserting `2002 and
2003.'; and
(3) by adding at the end the following:
`(IV) 30 percent of such capitation rate in 2004 (in which such
methodology should reflect a blend of 20 percent of only data from
inpatient settings and 10 percent of data from all
settings);
`(V) 40 percent of such amount in 2005 (in which such methodology
should reflect a blend of 10 percent of only data from inpatient
settings and 30 percent of data from all settings);
`(VI) 50 percent of such amount in 2006 (in which such methodology
should reflect data from all settings);
`(VII) 60 percent of such amount in 2007 (in which such
methodology should reflect data from all settings);
`(VIII) 70 percent of such amount in 2008 (in which such
methodology should reflect data from all settings);
`(IX) 80 percent of such amount in 2009 (in which such methodology
should reflect data from all settings);
`(X) 90 percent of such amount in 2010 (in which such methodology
should reflect data from all settings); and
`(XI) 100 percent of such amount in any subsequent year (in which
such methodology should reflect data from all
settings).'.
SEC. 607. 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 by adding at the end 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 120 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)(F) 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)(F).'.
(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)(F). This premium adjustment may be provided directly or
as an adjustment to any social
security, railroad retirement, and civil service retirement benefits, to the
extent which the Secretary determines that such an adjustment is appropriate and feasible
with the concurrence of the agencies responsible for the administration of
such benefits.'.
(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 premiums, if any.'.
(b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply to
years beginning with 2002.
SEC. 608. DELAY FROM JULY TO NOVEMBER 2000, IN DEADLINE FOR OFFERING AND
WITHDRAWING MEDICARE+CHOICE PLANS FOR 2001.
Notwithstanding any other provision of law, the deadline for a
Medicare+Choice organization to withdraw the offering of a Medicare+Choice
plan under part C of title XVIII of the Social Security Act (or otherwise to
submit information required for the offering of such a plan) for 2001 is
delayed from July 1, 2000, to November 15, 2000, and any such organization
that provided notice of withdrawal of such a plan during 2000 before the date
of enactment of this Act may rescind such withdrawal at any time before
November 15, 2000.
SEC. 609. 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 demonstrations established by section 2355 of the Deficit Reduction
Act of 1984 (Public Law 98-369; 98 Stat. 1103), as amended by section 13567(b)
of the Omnibus Budget Reconciliation Act of 1993 (Public Law 103-66; 107 Stat.
608), 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- The Secretary of Health and Human Services, not later
than 6 months after the date of enactment of this Act, 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. 610. MODIFICATION OF PAYMENT RULES FOR CERTAIN FRAIL ELDERLY MEDICARE
BENEFICIARIES.
(a) MODIFICATION OF PAYMENT RULES- Section 1853 (42 U.S.C. 1395w-23) is
amended--
(A) in paragraph (1)(A), by striking `subsections (e), (g), and (i)'
and inserting `subsections (e), (g), (i), and (j)';
(B) in paragraph (3)(D), by inserting `paragraph (4) and' after
`Subject to'; and
(C) by adding at the end the following new paragraph:
`(4) EXEMPTION FROM RISK
-ADJUSTMENT SYSTEM FOR FRAIL
ELDERLY BENEFICIARIES ENROLLED IN SPECIALIZED PROGRAMS-
`(A) IN GENERAL- In applying the risk -adjustment factors established
under paragraph (3) during the period described in subparagraph (B), the
limitation under paragraph (3)(C)(ii)(I) shall apply to a frail elderly
Medicare+Choice beneficiary (as defined in subsection (j)(3)) who is
enrolled in a Medicare+Choice plan under a specialized program for the
frail elderly (as defined in subsection (j)(2)) during the entire
period.
`(B) PERIOD OF APPLICATION- The period described in this subparagraph
begins with January 2001, and ends with the first month for which the
Secretary certifies to Congress that a comprehensive risk adjustment methodology under
paragraph (3)(C) that takes into account the factors described in
subsection (j)(1)(B) is being fully implemented.'; and
(2) by adding at the end the following new subsection:
`(j) SPECIAL RULES FOR FRAIL ELDERLY ENROLLED IN SPECIALIZED PROGRAMS FOR
THE FRAIL ELDERLY-
`(1) DEVELOPMENT AND IMPLEMENTATION OF NEW PAYMENT SYSTEM-
`(A) IN GENERAL- The Secretary shall develop and implement (as soon as
possible after the date of enactment of the Medicare, Medicaid, and SCHIP
Balanced Budget Refinement Act of 2000) a payment methodology for frail
elderly Medicare+Choice beneficiaries enrolled in a Medicare+Choice plan
under a specialized program for the frail elderly (as defined in paragraph
(2)(A)).
`(B) FACTORS DESCRIBED- The methodology developed and implemented
under subparagraph (A) shall take into account the prevalence, mix, and
severity of chronic conditions among frail elderly Medicare+Choice
beneficiaries and shall include--
`(i) medical diagnostic factors from all provider settings
(including hospital and nursing facility settings);
`(ii) functional indicators of health status; and
`(iii) such other factors as may be necessary to achieve appropriate
payments for plans serving such beneficiaries.
`(2) SPECIALIZED PROGRAM FOR THE FRAIL ELDERLY DEFINED-
`(A) IN GENERAL- In this part, the term `specialized program for the
frail elderly' means a program that the Secretary determines--
`(i) is offered under this part as a distinct part of a
Medicare+Choice plan;
`(ii) primarily enrolls frail elderly Medicare+Choice beneficiaries;
and
`(iii) has a clinical delivery system that is specifically designed
to serve the special needs of such beneficiaries and to coordinate
short-term and long-term care for such beneficiaries through the use of
a team described in subparagraph (B) and through the provision of
primary care services to such beneficiaries by means of such a team at
the nursing facility involved.
`(B) SPECIALIZED TEAM DESCRIBED- A team described in this
subparagraph--
`(II) a nurse practitioner or geriatric care manager;
and
`(ii) has as members individuals who--
`(I) have special training in the care and management of the frail
elderly beneficiaries; and
`(II) specialize in the care and management of such
beneficiaries.
`(3) FRAIL ELDERLY MEDICARE+CHOICE BENEFICIARY DEFINED- In this part,
the term `frail elderly Medicare+Choice beneficiary' means a Medicare+Choice
eligible individual who--
`(A) is residing in a skilled nursing facility (as defined in section
1819(a)) or a nursing facility (as defined in section 1919(a)) for an
indefinite period and without any intention of residing outside the
facility; and
`(B) has a severity of condition that makes the individual frail (as
determined under guidelines approved by the Secretary).'.
(b) EFFECTIVE DATE- The amendments made by this section shall take effect
on the date of enactment of this Act.
SEC. 611. 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. 612. INCLUSION OF COSTS OF DOD MILITARY TREATMENT FACILITY SERVICES TO
MEDICARE-ELIGIBLE BENEFICIARIES IN CALCULATION OF MEDICARE+CHOICE PAYMENT
RATES.
Section 1853(c)(3) (42 U.S.C. 1395w-23(c)(3)) is amended--
(1) in subparagraph (A), by striking `subparagraph (B)' and inserting
`subparagraphs (B) and (E)'; and
(2) by adding at the end the following new subparagraph:
`(E) INCLUSION OF COSTS OF CERTAIN DOD MILITARY TREATMENT FACILITY
SERVICES TO MEDICARE-ELIGIBLE BENEFICIARIES-
`(i) IN GENERAL- In determining the area-specific Medicare+Choice
capitation rate under subparagraph (A) for a year (beginning with 2001),
the annual per capita rate of payment for 1997 determined under section
1876(a)(1)(C) for a Medicare+Choice payment area that is within 1 or
more MTF affected areas (as defined in clause (ii)) shall be increased
by the sum of the MTF percentages (as described in clause (iii)) for the
MTF affected area or areas. The increase under this subparagraph shall
not be taken into account in computing the national standardized annual
Medicare+Choice capitation rate under paragraph (4)(B).
`(ii) MTF AFFECTED AREA DEFINED- In this subparagraph, the term `MTF
affected area' means, with respect to a military treatment facility (as
defined in subsection (a)(6) of section 1896), an area that includes the
following:
`(I) The Medicare+Choice payment area in which a military
treatment facility that was part of the medicare subvention
demonstration project under such section as of July 1, 2000, is
located.
`(II) Any Medicare+Choice payment area which is contiguous to the
area described in subclause (I) and located not farther than 40 miles
from the facility.
`(iii) MTF PERCENTAGE- For purposes of clause (i), the MTF
percentage for an MTF affected area is equal to the ratio
of--
`(I) the aggregate amount of costs incurred by the Department of
Defense in furnishing items and services to individuals entitled to
benefits under this title who received services from the military
treatment facility described in clause (ii) for that area in 1996 (as
determined pursuant to section 1896(j)(1)(A)), increased by the
national per capita Medicare+Choice growth percentage under paragraph
(6) for 1997, to
`(II) the average number of individuals residing in such area in
1996 entitled to benefits under part A and enrolled under part
B.'.
Subtitle B--Other Medicare+Choice Reforms
SEC. 621. AMOUNTS IN MEDICARE TRUST FUNDS AVAILABLE FOR SECRETARY'S SHARE OF
MEDICARE+CHOICE EDUCATION AND ENROLLMENT-RELATED COSTS.
(a) RELOCATION OF PROVISIONS- Section 1857(e)(2) (42 U.S.C.
1395w-27(e)(2)) is amended to read as follows:
`(2) COST-SHARING IN ENROLLMENT-RELATED COSTS- A Medicare+Choice
organization shall pay the fee established by the Secretary under section
1851(j)(3)(A).'.
(b) FUNDING FOR EDUCATION AND ENROLLMENT ACTIVITIES- Section 1851 (42
U.S.C. 1395w-21) is amended by adding at the end the following new
subsection:
`(j) FUNDING FOR BENEFICIARY EDUCATION AND ENROLLMENT ACTIVITIES-
`(1) SECRETARY'S ESTIMATE OF TOTAL COSTS- The Secretary shall annually
estimate the total cost for a fiscal year of carrying out this section,
section 4360 of the Omnibus Budget Reconciliation Act of 1990 (relating to
the health insurance counseling and assistance program), and related
activities.
`(2) TOTAL AMOUNT AVAILABLE- The total amount available to the Secretary
for a fiscal year for the costs of the activities described in paragraph (1)
shall be equal to the lesser of--
`(A) the amount estimated for such fiscal year under paragraph (1);
or
`(i) fiscal year 2001, $115,000,000; and
`(ii) fiscal year 2002 and each subsequent fiscal year, the amount
for the previous fiscal year, adjusted to account for inflation, any
change in the number of beneficiaries under this title, and any other
relevant factors.
`(3) COST-SHARING IN ENROLLMENT-RELATED COSTS-
`(A) AMOUNTS FROM MEDICARE+CHOICE ORGANIZATIONS-
`(i) IN GENERAL- The Secretary is authorized to charge a fee to each
Medicare+Choice organization with a contract under this part that is
equal to the organization's pro rata share (as determined by the
Secretary) of the Medicare+Choice portion (as defined in clause (ii)) of
the total amount available under paragraph (2) for a fiscal year. Any
amounts collected shall be available without further appropriation to
the Secretary for the costs of the activities described in paragraph
(1).
`(ii) MEDICARE+CHOICE PORTION DEFINED- For purposes of clause (i),
the term `Medicare+Choice portion' means, for a fiscal year, the ratio,
as estimated by the Secretary, of--
`(I) the average number of individuals enrolled in Medicare+Choice
plans during the fiscal year; to
`(II) the average number of individuals entitled to benefits under
part A, and enrolled under part B, during the fiscal
year.
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