Sec. 209. Extension and transition of 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 ; in clause (iii)(I), by inserting cost plan service after With respect to any portion of the ; in clause (iii)(II), by inserting cost plan service after With respect to any other portion of such ; 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), or where such contract has been extended or renewed but the eligible organization has informed the Secretary in writing not later than a date determined appropriate by the Secretary that such organization voluntarily plans not to seek renewal of the reasonable cost reimbursement contract, the following shall apply:
Notwithstanding such clause, such contract may be extended or renewed for the two years subsequent to 2016. The final year in which such contract is extended or renewed is referred to in this subsection as the last reasonable cost reimbursement contract year for the contract . The organization may not enroll a new enrollee under such contract during the last reasonable cost reimbursement contract year for the contract (but may continue to enroll new enrollees through the end of the year immediately preceding such year) unless such enrollee is any of the following:
An individual who chooses enrollment in the reasonable cost contract during the annual election period with respect to such last year. An individual whose spouse, at the time of the individual’s enrollment is an enrollee under the reasonable cost reimbursement contract. An individual who is covered under an employer group health plan that offers coverage through the reasonable cost reimbursement contract. An individual who becomes entitled to benefits under part A, or enrolled under part B, and was enrolled in a plan offered by the eligible organization immediately prior to the individual’s enrollment under the reasonable cost reimbursement contract.
Not later than a date determined appropriate by the Secretary prior to the beginning of the last reasonable cost reimbursement contract year for the contract, the organization shall provide notice to the Secretary as to whether the organization will apply to have the contract converted over, in whole or in part, and offered as a Medicare Advantage plan under part C for the year following the last reasonable cost reimbursement contract year for the contract. If the organization provides the notice described in subclause
(III)that the contract will be converted, in whole or in part, the organization shall, not later than a date determined appropriate by the Secretary, provide the Secretary with such information as the Secretary determines appropriate in order to carry out section 1851(c)(4) and to carry out section 1854(a)(5), including subparagraph (C)(ii) of such section. In the case that the organization enrolls a new enrollee under such contract during the last reasonable cost reimbursement contract year for the contract, the organization shall provide the individual with a notification that such year is the last year for such contract. 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, in whole or in part, the following shall apply: The deemed enrollment under section 1851(c)(4). The special rule for quality increase under section 1853(o)(4)(C). During the last reasonable cost reimbursement contract year for the contract and the year immediately preceding such year, the eligible organization, or the corporate parent organization of the eligible organization, shall be permitted to offer an MA plan in the area that such contract is being offered and enroll Medicare Advantage eligible individuals in such MA plan and such cost plan. . 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, 2017, an MA eligible individual described in clause
(i)or
(ii)of subparagraph
(B)is deemed, unless the individual elects otherwise, 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 the last reasonable cost reimbursement contract year of the contract (as described in subclause
(I)of section 1876(h)(5)(C)(iv)) pursuant to such section; 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 has a common ownership interest of control) that entered into such contract; and is offered in the service area where the individual resides; in the case of reasonable cost reimbursement contracts that provide coverage under parts A and B (and, to the extent the Secretary determines it to be feasible, contracts that provide only part B coverage), the difference between the estimated individual costs (as determined applicable by the Secretary) for the applicable MA plan and such costs for the predecessor cost plan does not exceed a threshold established by the Secretary; and the applicable MA plan— provides coverage for enrollees transitioning from the converted reasonable cost reimbursement contract to such plan to maintain current providers of services and suppliers and course of treatment at the time of enrollment for a period of at least 90 days after enrollment; and during such period, pays such providers of services and suppliers for items and services furnished to the enrollee an amount that is not less than the amount of payment applicable for such 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 is not, for such previous plan year, enrolled in a prescription drug plan 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, is enrolled in a prescription drug plan 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 45 days before the first day of the annual, coordinated election period under subsection (e)(3) for plan years beginning on or after January 1, 2017, the Secretary shall identify and notify 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— in the heading, by striking and inserting the following: Notification to newly eligible Medicare Advantage eligible individuals Notifications required.— ; and by adding at the end the following new clause: The Secretary shall require a Medicare Advantage organization that is offering a Medicare Advantage plan that has been converted from a reasonable cost reimbursement contract pursuant to section 1876(h)(5)(C)(iv) to mail, not later than 30 days prior to the first day of the annual, coordinated election period under subsection (e)(3) of a year, to any individual enrolled under such contract and 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 with respect to such plan 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; information about the special period for elections under subsection (e)(2)(F); and other information the Secretary may specify. . Section 1853(o)(4) of the Social Security Act ( 42 U.S.C. 1395w–23(o)(4) ) is amended by adding at the end the following new subparagraph: For purposes of applying paragraph
(1)and section 1854(b)(1)(C) for the first 3 plan years under this part in the case of an MA plan to which deemed enrollment applies under section 1851(c)(4)— such plan shall not be treated as a new MA plan (as defined in paragraph (3)(A)(iii)(II)); and in determining the star rating of the plan under subparagraph (A), to the extent that Medicare Advantage data for such plan is not available for a measure used to determine such star rating, the Secretary shall use data from the period in which such plan was a reasonable cost reimbursement contract. .
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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)(4)
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Sec. 209
Extension and transition of 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)
Cites 8 · showing 6Cited by 0 across 0 sources