DEFINITIONS; MISCELLANEOUS PROVISIONS

Sec. 1859. [42 U.S.C. 1395w–28] (a) Definitions Relating to Medicare+Choice Organizations.—In this part—

(1) Medicare+choice organization.—The term “Medicare+Choice organization” means a public or private entity that is certified under section 1856 as meeting the requirements and standards of this part for such an organization.

(2) Provider–sponsored organization.—The term “provider–sponsored organization” is defined in section 1855(d)(1).

(b) Definitions Relating to Medicare+Choice Plans.—

(1) Medicare+choice plan.—The term “Medicare+Choice plan” means health benefits coverage offered under a policy, contract, or plan by a Medicare+Choice organization pursuant to and in accordance with a contract under section 1857.

(2) Medicare+choice private fee–for–service plan.—The term “Medicare+Choice private fee–for–service plan” means a Medicare+Choice plan that—

(A) reimburses hospitals, physicians, and other providers at a rate determined by the plan on a fee–for–service basis without placing the provider at financial risk;

(B) does not vary such rates for such a provider based on utilization relating to such provider; and

(C) does not restrict the selection of providers among those who are lawfully authorized to provide the covered services and agree to accept the terms and conditions of payment established by the plan.

Nothing in subparagraph (B) shall be construed to preclude a plan from varying rates for such a provider based on the specialty of the provider, the location of the provider, or other factors related to such provider that are not related to utilization, or to preclude a plan from increasing rates for such a provider based on increased utilization of specified preventive or screening services.^[403]

(3) MSA plan.—

(A) In general.—The term “MSA plan” means a Medicare+Choice plan that—

(i) provides reimbursement for at least the items and services described in section 1852(a)(1) in a year but only after the enrollee incurs countable expenses (as specified under the plan) equal to the amount of an annual deductible (described in subparagraph (B));

(ii) counts as such expenses (for purposes of such deductible) at least all amounts that would have been payable under parts A and B, and that would have been payable by the enrollee as deductibles, coinsurance, or copayments, if the enrollee had elected to receive benefits through the provisions of such parts; and

(iii) provides, after such deductible is met for a year and for all subsequent expenses for items and services referred to in clause (i) in the year, for a level of reimbursement that is not less than—

(I) 100 percent of such expenses, or

(II) 100 percent of the amounts that would have been paid (without regard to any deductibles or coinsurance) under parts A and B with respect to such expenses,

whichever is less.

(B) Deductible.—The amount of annual deductible under an MSA plan—

(i) for contract year 1999 shall be not more than $6,000; and

(ii) for a subsequent contract year shall be not more than the maximum amount of such deductible for the previous contract year under this subparagraph increased by the national per capita Medicare+Choice growth percentage under section 1853(c)(6) for the year.

If the amount of the deductible under clause (ii) is not a multiple of $50, the amount shall be rounded to the nearest multiple of $50.

(4) MA regional plan.—The term “MA regional plan” means an MA plan described in section 1851(a)(2)(A)(i)—

(A) that has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan;

(B) that provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and

(C) the service area of which is one or more entire MA regions.

(5) MA local plan.—The term “MA local plan” means an MA plan that is not an MA regional plan.

(6) Specialized ma plans for special needs individuals.—

(A) In general.—The term “specialized MA plan for special needs individuals” means an MA plan that exclusively serves special needs individuals (as defined in subparagraph (B)) and that, as of January 1, 2010, meets the applicable requirements of paragraph (2), (3), or (4) of subsection (f), as the case may be.^[404]

(B) Special needs individual.—The term “special needs individual” means an MA eligible individual who—

(i) is institutionalized (as defined by the Secretary);

(ii)[405] is entitled to medical assistance under a State plan under title XIX; or

(iii) meets such requirements as the Secretary may determine would benefit from enrollment in such a specialized MA plan described in subparagraph (A) for individuals with severe or disabling chronic conditions who have one or more comorbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care^[406].

The Secretary may waive application of section 1851(a)(3)(B) in the case of an individual described in clause (i), (ii), or (iii) of this subparagraph and may apply rules similar to the rules of section 1894(c)(4) for continued eligibility of special needs individuals.

(c) Other References to Other Terms.—

(1) Medicare+choice eligible individual.—The term “Medicare+Choice eligible individual” is defined in section 1851(a)(3).

(2) Medicare+choice payment area.—The term “Medicare+Choice payment area” is defined in section 1853(d).

(3) National per capita medicare+choice growth percentage.—The “national per capita Medicare+Choice growth percentage” is defined in section 1853(c)(6).

(4) Medicare+choice monthly basic beneficiary premium; medicare+choice monthly supplemental beneficiary premium.—The terms “Medicare+Choice monthly basic beneficiary premium” and “Medicare+Choice monthly supplemental beneficiary premium” are defined in section 1854(a)(2).

(5) MA local area.—The term “MA local area” is defined in section 1853(d)(2).

(d) Coordinated Acute and Long–Term Care Benefits Under A Medicare+Choice Plan.—Nothing in this part shall be construed as preventing a State from coordinating benefits under a medicaid plan under title XIX with those provided under a Medicare+Choice plan in a manner that assures continuity of a full–range of acute care and long–term care services to poor elderly or disabled individuals eligible for benefits under this title and under such plan.

(e) Restriction on Enrollment for Certain Medicare+Choice Plans.—

(1) In general.—In the case of a Medicare+Choice religious fraternal benefit society plan described in paragraph (2), notwithstanding any other provision of this part to the contrary and in accordance with regulations of the Secretary, the society offering the plan may restrict the enrollment of individuals under this part to individuals who are members of the church, convention, or group described in paragraph (3)(B) with which the society is affiliated.

(2) Medicare+choice religious fraternal benefit society plan described.—For purposes of this subsection, a Medicare+Choice religious fraternal benefit society plan described in this paragraph is a Medicare+Choice plan described in section 1851(a)(2) that—

(A) is offered by a religious fraternal benefit society described in paragraph (3) only to members of the church, convention, or group described in paragraph (3)(B); and

(B) permits all such members to enroll under the plan without regard to health status–related factors. Nothing in this subsection shall be construed as waiving any plan requirements relating to financial solvency.

(3) Religious fraternal benefit society defined.—For purposes of paragraph (2)(A), a “religious fraternal benefit society” described in this section is an organization that—

(A) is described in section 501(c)(8) of the Internal Revenue Code of 1986 and is exempt from taxation under section 501(a) of such Act;

(B) is affiliated with, carries out the tenets of, and shares a religious bond with, a church or convention or association of churches or an affiliated group of churches;

(C) offers, in addition to a Medicare+Choice religious fraternal benefit society plan, health coverage to individuals not entitled to benefits under this title who are members of such church, convention, or group; and

(D) does not impose any limitation on membership in the society based on any health status–related factor.

(4) Payment adjustment.—Under regulations of the Secretary, in the case of individuals enrolled under this part under a Medicare+Choice religious fraternal benefit society plan described in paragraph (2), the Secretary shall provide for such adjustment to the payment amounts otherwise established under section 1854 as may be appropriate to assure an appropriate payment level, taking into account the actuarial characteristics and experience of such individuals.

(f)[407] Restriction on Enrollment for Specialized MA Plans for Special Needs Individuals^[408].—In the case of a specialized MA plan for special needs individuals (as defined in subsection (b)(6)), notwithstanding any other provision of this part and in accordance with regulations of the Secretary and for periods before January 1, 2011^[409], the plan may restrict the enrollment of individuals under the plan to individuals who are within one or more classes of special needs individuals.^[410]

(2)[411] Additional requirements for institutional snps.—In the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(i), the applicable requirements described in this paragraph are as follows:

(A) Each individual that enrolls in the plan on or after January 1, 2010, is a special needs individuals described in subsection (b)(6)(B)(i). In the case of an individual who is living in the community but requires an institutional level of care, such individual shall not be considered a special needs individual described in subsection (b)(6)(B)(i) unless the determination that the individual requires an institutional level of care was made—

(i) using a State assessment tool of the State in which the individual resides; and

(ii) by an entity other than the organization offering the plan.

(B) The plan meets the requirements described in paragraph (5).

(3)[412] Additional requirements for dual snps.—In the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii), the applicable requirements described in this paragraph are as follows:

(A) Each individual that enrolls in the plan on or after January 1, 2010, is a special needs individuals described in subsection (b)(6)(B)(ii).

(B) The plan meets the requirements described in paragraph (5).

(C) The plan provides each prospective enrollee, prior to enrollment, with a comprehensive written statement (using standardized content and format established by the Secretary) that describes—

(i) the benefits and cost-sharing protections that the individual is entitled to under the State Medicaid program under title XIX; and

(ii) which of such benefits and cost-sharing protections are covered under the plan.

Such statement shall be included with any description of benefits offered by the plan.

(D) The plan has a contract with the State Medicaid agency to provide benefits, or arrange for benefits to be provided, for which such individual is entitled to receive as medical assistance under title XIX. Such benefits may include long-term care services consistent with State policy.

(4)[413] Additional requirements for severe or disabling chronic condition snps.—In the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(iii), the applicable requirements described in this paragraph are as follows:

(A) Each individual that enrolls in the plan on or after January 1, 2010, is a special needs individual described in subsection (b)(6)(B)(iii).

(B) The plan meets the requirements described in paragraph (5).

(5)[414] Care management requirements for all snps.—The requirements described in this paragraph are that the organization offering a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(i)—

(A) have in place an evidenced-based model of care with appropriate networks of providers and specialists; and

(B) with respect to each individual enrolled in the plan—

(i) conduct an initial assessment and an annual reassessment of the individual's physical, psychosocial, and functional needs;

(ii) develop a plan, in consultation with the individual as feasible, that identifies goals and objectives, including measurable outcomes as well as specific services and benefits to be provided; and

(iii) use an interdisciplinary team in the management of care.

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^[403]  P.L. 110-275, §162(b), added this sentence, effective July 15, 2008.

^[404]  P.L. 110–275, §164(c)(1)(A), inserts “and that, as of January 1, 2010, meets the applicable requirements of paragraph (2), (3), or (4) of subsection (f), as the case may be”.

^[405]  P.L. 110–275, §164(h), provides that Nothing in the provisions of, or amendments made by, this section [ 164] shall affect the benefits available under the Medicaid program under title XIX of the Social Security Act for special needs individuals described in section 1859(b)(6)(B)(ii) of such Act (42 U.S.C. 1395w– 28(b)(6)(B)(ii)).

^[406]  P.L. 110–275, §164(d)(2), inserts “who have one or more comorbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care”, applicable to plan years beginning on or after January 1, 2010.

^[407]  See Vol. II, P.L. 110-173, §108(b), with respect to a moratorium on the designation of plans and the enrollment in new plans.

See Vol. II, P.L. 110-275, §164(c)(2), with respect to authority to operate but not service area expansion for dual SNPs; §164(c(3), with respect to resources for State agencies; and §164(c(4), with respect to no requirement for contract.

^[408]  P.L. 110-275, §164(c)(1)(B)(i), amends the heading in its entirety to read, “Requirements Regarding Enrollment in Specialized MA Plans for Special Needs Individuals”, applicable to plan years beginning on or after January 1, 2010.

^[409]  P.L. 110-173, §108(a), struck out “2009” and substituted “2010*”, effective December 29, 2007.

P.L. 110-275, §164(a), struck out “2010” and substituted “2011”, effective July 15, 2008.

^[410]  P.L. 110-275, §164(c)(1)(B)(ii), designates this paragraph as paragraph (1) with the heading “Requirements for enrollment.—”, applicable to plan years beginning on or after January 1, 2010.

^[411]  P.L. 110–275, §164(c)(1)(B)(iii), adds paragraph (2), applicable to plan years beginning on or after January 1, 2010, and applicable to all specialized Medicare Advantage plans for special needs individuals regardless of when the plan first entered the Medicare Advantage program under part C of title XVIII of the Social Security Act.

^[412]  P.L. 110–275, §164(c)(1)(B)(iii), adds paragraph (3), applicable to plan years beginning on or after January 1, 2010, and applicable to all specialized Medicare Advantage plans for special needs individuals regardless of when the plan first entered the Medicare Advantage program under part C of title XVIII of the Social Security Act.

^[413]  P.L. 110–275, §164(c)(1)(B)(iii), adds paragraph (4), applicable to plan years beginning on or after January 1, 2010, and applicable to all specialized Medicare Advantage plans for special needs individuals regardless of when the plan first entered the Medicare Advantage program under part C of title XVIII of the Social Security Act.

^[414]  P.L. 110–275, §164(d)(1), adds paragraph (5), applicable to plan years beginning on or after January 1, 2010, and applicable to all specialized Medicare Advantage plans for special needs individuals regardless of when the plan first entered the Medicare Advantage program under part C of title XVIII of the Social Security Act.