medicare amendments

medicare amendments Sec. 201. (a) Section 1878(b) of the Social Security Act is amended to read as follows: “(b) (1) The term ‘health maintenance organization’ means a legal entity which provides health services on a prepayment basis to individuals enrolled with such organizations and which— “(A) provides to its enrollees who are insured for benefits under parts A and B of this title or for benefits under part B alone, through institutions, entities, and persons meeting the applicable requirements of section 1861, all of the services and benefits covered under such parts (to the extent applicable under subparagraph (A) or (B) of subsection (a)(1)) which are available to individuals residing in the geographic area served by the organization; “(B) provides such services in the manner prescribed by section 1301(b) of the Public Health Service Act, except that solely for the purposes of this section— “(i) the term ‘basic health services’ and references thereto shall be deemed to refer to the services and benefits included under parts A and B of this title.; “(ii) the organization shall not be required to fix the basic health services payment under a community rating system; “(iii) the additional nominal payments authorized by section 1301(b) (1) (D) of such Act shall not exceed the limits applicable under subsection (g) of this section: and “(iv) payment for basic health services provided by the organization to its enrollees under this section or for services such enrollees receive other than through the organization shall be made as provided for by this title; “(C) is organized and operated in the manner prescribed by section 1301(c) of the Public Health Service Act, except that solely for the purposes of this section— “(i) the term ‘basic health services’ and references thereto shall be deemed to refer to the services and benefits included under parts A and B of this title: “(ii) the organization shall not be reimbursed for the cost of reinsurance except as permitted by subsection (i) of this section; and “(iii) the organization shall have an open enrollment period as provided for in subsection (k) of this section. “(2) (A) The duties and functions of the Secretary, insofar as they involve making determinations as to whether an organization is a ‘health maintenance organization’ within the meaning of paragraph (1), shall be administered through the Assistant Secretary for Health and in the Office of the Assistant Secretary for Health, and the admin-90 STAT. 1957istration of such duties and functions shall be integrated with the administration of section 1312 (a) and (b) of the Public Health Service Act. “(B) Except as provided in subparagraph (A), the Secretary shall administer the provisions of this section through the Commissioner of Social Security.”. (b) Section 1876(h) of such Act is amended to read as follows: “(h) (1) Except as provided in paragraph (2), each health maintenance organization with which the Secretary enters into a contract under this section shall have an enrolled membership at least half of which consists of individuals who have not attained age 65. “(2) The Secretary may waive the requirement imposed in paragraph (1) for a period of not more than three years from the date a health maintenance organization first enters into an agreement with the Secretary pursuant to subsection (i), but only for so long as such organization demonstrates to the satisfaction of the Secretary by the submission of its plan for each year that it is making continuous efforts and progress toward compliance with the provisions of paragraph (1) within such three-year period.”. (c) Section 1876(i)(6) (B) of such Act is amended by striking out “(other than those with respect to out-of-area services)” and inserting in lieu thereof “(other than costs with respect to out-of-area services and, in the case of an organization which has entered into a risks haring contract with the Secretary pursuant to paragraph (2) (A), the cost of providing any member with basic health services the aggregate value of which exceeds $5,000 in any year)”. (d) Section 1876 is amended by adding at the end thereof the following— “(k) Each health maintenance organization with which the Secretary enters into a contract under this section shall have an open enrollment period at least every year under which it accepts up to the limits of its capacity and without restrictions, except as may be authorized in regulations, individuals who are eligible to enroll under subsection (d) in the order in which they apply for enrollment (unless to do so would result in failure to meet the requirements of subsection (h)) or would result in enrollment of enrollees substantially non representative, as determined in accordance with regulations of the Secretary, of the population in the geographic area served by such health maintenance organization.”. (e) The amendments made by this section shall be effective with respect to contracts entered into between the Secretary and health maintenance organizations under section 1876 of the Social Security Act on and after the first day of the first calendar month which begins more than 30 days after the date of enactment of this Act.