Sec. 207. Reasonable cost reimbursement contracts
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Section 1876(h)(5)(C) of the Social Security Act ( 42 U.S.C. 1395mm(h)(5)(C) ) is amended— in clause (ii), in the matter preceding subclause (I), by striking For any and inserting Subject to clause (iv), for any ; and by adding at the end the following new clauses: In the case of an eligible organization that is offering a reasonable cost reimbursement contract that may no longer be extended or renewed because of the application of clause (ii)— notwithstanding such clause, such contract may be extended or renewed for one last reasonable cost reimbursement contract year; the organization may not enroll any new enrollees under such contract during such last reasonable cost reimbursement contract year; and on a date determined by the Secretary prior to the beginning of such last reasonable cost reimbursement contract year, the organization shall provide notice to the Secretary as to whether or not the organization will apply to have the contract converted over and offered as a Medicare Advantage plan under part C for the year following such last reasonable cost reimbursement contract year.
If an eligible organization that is offering a reasonable cost reimbursement contract that is extended or renewed pursuant to clause
(iv)provides the notice described in clause (iv)(III) that the contract will be converted— the deemed enrollment under section 1851(c)(4) shall apply; and the special rule for quality increases under 1853(o)(3)(A)(iv) shall apply. . Section 1851(c) of the Social Security Act ( 42 U.S.C. 1395w–21(c) ) is amended— in paragraph (1), by striking Such elections and inserting Subject to paragraph (4), such elections ; and by adding at the end the following: On the first day of the annual, coordinated election period under subsection (e)(3) for plan years beginning on or after January 1, 2016, an MA eligible individual described in clause
(i)or
(ii)of subparagraph
(B)is deemed to have elected to receive benefits under this title through an applicable MA plan (and shall be enrolled in such plan) beginning with such plan year, if— the individual is enrolled in a reasonable cost reimbursement contract under section 1876(h) in the previous plan year; such reasonable cost reimbursement contract was extended or renewed for one last reasonable cost reimbursement contract year pursuant to section 1876(h)(5)(C)(iv); the eligible organization that is offering such reasonable cost reimbursement contract provided the notice described in subclause
(III)of such section that the contract was to be converted; the applicable MA plan— is the plan that was converted from the reasonable cost reimbursement contract described in clause (iii); is offered by the same entity (or an organization affiliated with such entity) that entered into such contract; and is offered in the service area where the individual resides; the amount of the MA monthly basic beneficiary premium for such applicable MA plan with respect to the plan year does not exceed monthly premiums under such reasonable cost reimbursement contract for the previous plan year by more than 10 percent; the applicable MA plan provides benefits, premiums, and access to providers that are comparable to the benefits, premiums, and access to providers under such reasonable cost reimbursement contract for the previous plan year; and the applicable MA plan— allows enrollees transitioning from the converted reasonable cost contract to such plan to maintain current providers and course of treatment at the time of enrollment for at least 90 days after enrollment; and during such period, pays non-contracting providers for items and services furnished to the enrollee an amount that is not less than the amount of payment applicable for those items and services under the original medicare fee-for-service program under parts A and B. An MA eligible individual described in this clause, with respect to a plan year, is an MA eligible individual who is enrolled in a reasonable cost reimbursement contract under section 1876(h) in the previous plan year and who does not, for such previous plan year, receive any prescription drug coverage under part D, including coverage under section 1860D–22. An MA eligible individual described in this clause, with respect to a plan year, is an MA eligible individual who is enrolled in a reasonable cost reimbursement contract under section 1876(h) in the previous plan year and who, for such previous plan year, receives prescription drug coverage under part D— through such contract; or through a prescription drug plan, if the sponsor of such plan is the same entity (or an organization affiliated with such entity) that entered into such contract. In this paragraph, the term applicable MA plan means, in the case of an individual described in— subparagraph (B)(i), an MA plan that is not an MA–PD plan; and subparagraph (B)(ii), an MA–PD plan. Not later than 30 days before the first day of the annual, coordinated election period under subsection (e)(3) for plan years beginning on or after January 1, 2016, the Secretary shall identify the individuals who will be subject to deemed elections under subparagraph
(A)on the first day of such period. . Section 1851(e)(2) of the Social Security Act ( 42 U.S.C. 1395w–21(e)(4) ) is amended by adding at the end the following: At any time during the period beginning after the last day of the annual, coordinated election period under paragraph
(3)in which an individual is deemed to have elected to enroll in an MA plan or MA–PD plan under subsection (c)(4) and ending on the last day of February of the first plan year for which the individual is enrolled in such plan, such individual may change the election under subsection (a)(1) (including changing the MA plan or MA–PD plan in which the individual is enrolled). An individual may exercise the right under clause
(i)only once during the applicable period described in such clause. The limitation under this clause shall not apply to changes in elections effected during an annual, coordinated election period under paragraph
(3)or during a special enrollment period under paragraph (4). . Section 1851(e)(6)(A) of the Social Security Act ( 42 U.S.C. 1395w–21(e)(6)(A) ) is amended by striking paragraph (1), and inserting paragraph (1), during the period described in paragraph (2)(F), . Section 1860D–1(b)(1)(B) of such Act ( 42 U.S.C. 1395w–101(b)(1)(B) ) is amended— in clause (ii), by adding and paragraph
(4)after paragraph (3)(A) ; and in clause
(iii)by striking and
(E)and inserting (E), and
(F). Section 1851(a)(3)(B) of the Social Security Act ( 42 U.S.C. 1395w–21(a)(3)(B) ) is amended by adding at the end the following flush sentence: An individual who develops end-stage renal disease while enrolled in a reasonable cost reimbursement contract under section 1876(h) shall be treated as an MA eligible individual for purposes of applying the deemed enrollment under subsection (c)(4). . Section 1851(d)(2)(B) of the Social Security Act ( 42 U.S.C. 1395w–21(d)(2)(B) ) is amended— by striking the subparagraph heading and inserting the following: ; and
(i)Notification to newly eligible Medicare Advantage eligible individuals.— by adding at the end the following: The Secretary shall, not later than 15 days prior to the first day of the annual, coordinated election period under subsection (e)(3) of a year, mail to any individual identified by the Secretary under subsection (c)(4)(D) for such year— a notification that such individual will, on such day, be deemed to have made an election to receive benefits under this title through an MA plan or MA–PD plan (and shall be enrolled in such plan) for the next plan year under subsection (c)(4)(A), but that the individual may make a different election during the annual, coordinated election period for such year; the information described in subparagraph (A); a description of the differences between such MA plan or MA–PD plan and the reasonable cost reimbursement contract in which the individual was most recently enrolled with respect to benefits covered under such plans, including cost-sharing, premiums, drug coverage, and provider networks; and information about the special period for elections under subsection (e)(2)(F). . Section 1853(o)(3)(A) of the Social Security Act ( 42 U.S.C. 1395w–23(o)(3)(A) ) is amended by adding at the end the following new clause: In applying paragraph
(1)for the first 2 plan years under this part in the case of a plan that is a new MA plan (as defined in clause (iii)(II)) to which deemed enrollment applies under section 1851(e)(4), the Secretary shall use the star rating that applied to the converted reasonable cost reimbursement contract for the year preceding the first plan year for such plan under this part. .
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- 42 USC 1395w–21(c)
- 42 USC 1395w–21(e)(4)
- 42 USC 1395w–21(e)(6)(A)
- 42 USC 1395w–101(b)(1)(B)
- 42 USC 1395w–21(a)(3)(B)
- 42 USC 1395w–21(d)(2)(B)
- 42 USC 1395w–23(o)(3)(A)
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Sec. 207
Reasonable cost reimbursement contracts
Cite42 USC 1395w–21(c)
Cite42 USC 1395w–21(e)(4)
Cite42 USC 1395w–21(e)(6)(A)
Cite42 USC 1395w–101(b)(1)(B)
Cite42 USC 1395w–21(a)(3)(B)
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