HR 4555 IH

106th CONGRESS

2d Session

H. R. 4555

To provide for a 6-year demonstration project to stabilize coverage and benefits under the Medicare+Choice Program.

IN THE HOUSE OF REPRESENTATIVES

May 25, 2000

Mr. BROWN of Ohio introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To provide for a 6-year demonstration project to stabilize coverage and benefits under the Medicare+Choice Program.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the `Medicare+Choice Reliability Act of 2000'.

SEC. 2. ESTABLISHMENT OF 6-YEAR DEMONSTRATION PROJECT TO STABILIZE COVERAGE AND BENEFITS UNDER THE MEDICARE+CHOICE PROGRAM.

(a) IN GENERAL- The Secretary of Health and Human Services shall establish under this section a demonstration project under which Medicare+Choice organizations under part C of title XVIII of the Social Security Act may elect to provide Medicare+Choice plans in accordance with the special provisions of the project.

(b) DURATION- The project shall extend over a period of 6 years.

(1) PAYMENT AMOUNT BASED ON PAYMENTS UNDER TRADITIONAL FEE-FOR-SERVICE PROGRAM- There shall be substituted for the annual Medicare+Choice capitation rate under section 1853(a) the fee-for-service-related amount described in subsection (d). Payment of such amount is subject to risk-adjustment in the manner described in section 1853(a)(3) of the Social Security Act (42 U.S.C. 1395w-23(a)(3)).

(2) 3-YEAR CONTRACT- The period of the contract under section 1857(c)(1) of such Act (42 U.S.C. 1395w-27(c)(1)) shall be for a term of 3 years. For the duration of the contract the Medicare+Choice organization--

(A) may not modify premiums and benefits, unless the Secretary determines that such modifications would increase the value of the coverage; and

(B) may not withdraw from any part of the service area.

(3) SERVICE AREA-

(A) ESTABLISHMENT- Taking into account factors such as commercial rating patterns, the Secretary shall designate geographic areas as service areas for purposes of the project. Such areas may be portions of a State or an entire State. Each county or equivalent area shall be in one, and only one, service area. No Medicare+Choice plan under the project may serve any part of a service area without serving all parts of that service area.

(B) UNIFORM BENEFITS IN A SERVICE AREA-

(i) IN GENERAL- Subject to clause (i), a Medicare+Choice plan shall provide the same benefits to all enrollees in a service area.

(ii) ADAPTION BY HEALTH MAINTENANCE ORGANIZATIONS- In applying clause (i) in the case of a plan that is a health maintenance organization, if limitations in provider contracts prevent the plan from maintaining the provider contracts in certain parts of a service area, the plan may establish a preferred provider network or fee-for-service plan in those parts of the service area, but only if the cost-sharing applicable to such a network or plan is not established in a manner that discourages enrollment of residents in those parts of the service area.

(4) NO REQUIREMENT FOR SUPPLEMENTAL BENEFITS- The provisions of sections 1852(a)(1)(B), 1854(e), and 1854(f)(1)(A) (relating to requirement for supplemental benefits) of the Social Security Act (42 U.S.C. 1395w-22(a)(1)(B), 1395w-24(e), 1395w-24(f)) shall not apply.

(d) FEE-FOR-SERVICE-RELATED PAYMENT AMOUNT-

(1) IN GENERAL- The amount described in this subsection for a service area is the Secretary's estimate of the adjusted average per capita cost (as

determined under section 1876(a)(4) of the Social Security Act, 42 U.S.C. 1395mm(a)(4)) for the service area for the contract year.

(2) EXCLUSION OF MEDICAL EDUCATION COSTS- In determining the amounts under paragraph (1), the Secretary shall not take into account payments attributable to--

(A) graduate medical education payments under section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h));

(B) disproportionate share hospital payments described in section 1886(d)(5)(F) of such Act (42 U.S.C. 1395ww(d)(5)(F)); or

(e) SANCTIONS FOR VIOLATION OF PROJECT TERMS-

(1) IN GENERAL- The Secretary may provide for such sanctions as may be appropriate to assure that Medicare+Choice organizations that elect to participate in the project meet the contractual terms of the contract, including maintaining benefits and coverage during the entire period of the contract.

(2) CONSTRUCTION- Nothing in this subsection shall be construed as preventing the Secretary from terminating a Medicare+Choice organization's participation in the project for cause or for other conditions for which a contract under section 1857 of the Social Security Act (42 U.S.C. 1395w-27) could be terminated.

(f) RELATION TO MEDICARE PART C- Medicare+Choice organizations participating in the project shall comply with the provisions of the Medicare+Choice program except to the extent that such provisions are superseded by the provisions in the project.

(g) EVALUATION AND REPORT- The Secretary shall continuously assess the effectiveness of the project in stabilizing coverage and benefits under the Medicare+Choice program. The Secretary shall submit a report to Congress on such evaluation after the completion of 4 years of the project.

(h) DEFINITIONS- For purposes of this section:

(1) MEDICARE+CHOICE ORGANIZATION; MEDICARE+CHOICE PLAN- The terms `Medicare+Choice organization' and `Medicare+Choice plan' have the meanings given such terms under the Medicare+Choice program.

(2) MEDICARE+CHOICE PROGRAM- The term `Medicare+Choice program' means the program under part C of title XVIII of the Social Security Act.

(3) PROJECT- The term `project' means the demonstration project established under this section.

(4) SECRETARY- The term `Secretary' means the Secretary of Health and Human Services .

END