42 USC 1395w-27 - Contracts with Medicare+Choice organizations

U.S Code last checked for updates: Jan 19, 2025

§ 1395w–27.

Contracts with Medicare+Choice organizations

(a)

In general

(b)

Minimum enrollment requirements

(1)

In general

Subject to paragraph (2), the Secretary may not enter into a contract under this section with a Medicare+Choice organization unless the organization has—

(A)

at least 5,000 individuals (or 1,500 individuals in the case of an organization that is a provider-sponsored organization) who are receiving health benefits through the organization, or

(B)

at least 1,500 individuals (or 500 individuals in the case of an organization that is a provider-sponsored organization) who are receiving health benefits through the organization if the organization primarily serves individuals residing outside of urbanized areas.

(2)

Application to MSA plans

(3)

Allowing transition

(c)

Contract period and effectiveness

(1)

Period

(2)

Termination authority

In accordance with procedures established under subsection (h), the Secretary may at any time terminate any such contract if the Secretary determines that the organization—

(A)

has failed substantially to carry out the contract;

(B)

is carrying out the contract in a manner inconsistent with the efficient and effective administration of this part; or

(C)

no longer substantially meets the applicable conditions of this part.

(3)

Effective date of contracts

(4)

Previous terminations

(A)

In general

(B)

Earlier re-entry permitted where change in payment policy

(5)

Contracting authority

(d)

Protections against fraud and beneficiary protections

(1)

Periodic auditing

(2)

Inspection and audit

Each contract under this section shall provide that the Secretary, or any person or organization designated by the Secretary—

(A)

shall have the right to timely inspect or otherwise evaluate (i) the quality, appropriateness, and timeliness of services performed under the contract, and (ii) the facilities of the organization when there is reasonable evidence of some need for such inspection, and

(B)

shall have the right to timely audit and inspect any books and records of the Medicare+Choice organization that pertain (i) to the ability of the organization to bear the risk of potential financial losses, or (ii) to services performed or determinations of amounts payable under the contract.

(3)

Enrollee notice at time of termination

(4)

Disclosure

(A)

In general

Each Medicare+Choice organization shall, in accordance with regulations of the Secretary, report to the Secretary financial information which shall include the following:

(i)

Such information as the Secretary may require demonstrating that the organization has a fiscally sound operation.

(ii)

A copy of the report, if any, filed with the Secretary containing the information required to be reported under

by disclosing entities.

(iii)

A description of transactions, as specified by the Secretary, between the organization and a party in interest. Such transactions shall include—

(I)

any sale or exchange, or leasing of any property between the organization and a party in interest;

(II)

any furnishing for consideration of goods, services (including management services), or facilities between the organization and a party in interest, but not including salaries paid to employees for services provided in the normal course of their employment and health services provided to members by hospitals and other providers and by staff, medical group (or groups), individual practice association (or associations), or any combination thereof; and

(III)

any lending of money or other extension of credit between an organization and a party in interest.

The Secretary may require that information reported respecting an organization which controls, is controlled by, or is under common control with, another entity be in the form of a consolidated financial statement for the organization and such entity.

(B)

“Party in interest” defined

For the purposes of this paragraph, the term “party in interest” means—

(i)

any director, officer, partner, or employee responsible for management or administration of a Medicare+Choice organization, any person who is directly or indirectly the beneficial owner of more than 5 percent of the equity of the organization, any person who is the beneficial owner of a mortgage, deed of trust, note, or other interest secured by, and valuing more than 5 percent of the organization, and, in the case of a Medicare+Choice organization organized as a nonprofit corporation, an incorporator or member of such corporation under applicable State corporation law;

(ii)

any entity in which a person described in clause (i)—

(I)

is an officer or director;

(II)

is a partner (if such entity is organized as a partnership);

(III)

has directly or indirectly a beneficial interest of more than 5 percent of the equity; or

(IV)

has a mortgage, deed of trust, note, or other interest valuing more than 5 percent of the assets of such entity;

(iii)

any person directly or indirectly controlling, controlled by, or under common control with an organization; and

(iv)

any spouse, child, or parent of an individual described in clause (i).

(C)

Access to information

(5)

Loan information

(6)

Review to ensure compliance with care management requirements for specialized Medicare Advantage plans for special needs individuals

(e)

Additional contract terms

(1)

In general

(2)

Cost-sharing in enrollment-related costs

Authorization of appropriations

(D)

Limitation

In any fiscal year the fees collected by the Secretary under subparagraph (B) shall not exceed the lesser of—

(i)

the estimated costs to be incurred by the Secretary in the fiscal year in carrying out the activities described in section 1395w–21 of this title and section 1395w–101(c) of this title and section 1395b–4 of this title; or

(ii)

(I)

$200,000,000 in fiscal year 1998;

(II)

$150,000,000 in fiscal year 1999;

(III)

$100,000,000 in fiscal year 2000;

(IV)

the Medicare+Choice portion (as defined in subparagraph (E)) of $100,000,000 in fiscal year 2001 and each succeeding fiscal year before fiscal year 2006; and

(V)

the applicable portion (as defined in subparagraph (F)) of $200,000,000 in fiscal year 2006 and each succeeding fiscal year.

(E)

Medicare+Choice portion defined

In this paragraph, the term “Medicare+Choice portion” means, for a fiscal year, the ratio, as estimated by the Secretary, of—

(i)

the average number of individuals enrolled in Medicare+Choice plans during the fiscal year, to

(ii)

the average number of individuals entitled to benefits under part A, and enrolled under part B, during the fiscal year.

(F)

Applicable portion defined

In this paragraph, the term “applicable portion” means, for a fiscal year—

(i)

with respect to MA organizations, the Secretary’s estimate of the total proportion of expenditures under this subchapter that are attributable to expenditures made under this part (including payments under part D that are made to such organizations); or

(ii)

with respect to PDP sponsors, the Secretary’s estimate of the total proportion of expenditures under this subchapter that are attributable to expenditures made to such sponsors under part D.

(3)

Agreements with federally qualified health centers

(A)

Payment levels and amounts

(B)

Cost-sharing

(4)

Requirement for minimum medical loss ratio

If the Secretary determines for a contract year (beginning with 2014) that an MA plan has failed to have a medical loss ratio of at least .85—

(A)

the MA plan shall remit to the Secretary an amount equal to the product of—

(i)

the total revenue of the MA plan under this part for the contract year; and

(ii)

the difference between .85 and the medical loss ratio;

(B)

for 3 consecutive contract years, the Secretary shall not permit the enrollment of new enrollees under the plan for coverage during the second succeeding contract year; and

(C)

the Secretary shall terminate the plan contract if the plan fails to have such a medical loss ratio for 5 consecutive contract years.

(5)

Communicating plan corrective actions against opioids over-prescribers

(A)

In general

(B)

Process

(C)

Regulations

For purposes of this paragraph, including as applied under section 1395w–112(b)(3)(D) of this title, the Secretary shall, pursuant to rulemaking—

(i)

specify a definition for the term “inappropriate prescribing” and a method for determining if a provider of services prescribes inappropriate prescribing; and

(ii)

establish the process described in subparagraph (B) and the types of information that shall be submitted through such process.

(f)

Prompt payment by Medicare+Choice organization

(1)

Requirement

(2)

Secretary’s option to bypass noncomplying organization

(3)

Incorporation of certain prescription drug plan contract requirements

The following provisions shall apply to contracts with a Medicare Advantage organization offering an MA–PD plan in the same manner as they apply to contracts with a PDP sponsor offering a prescription drug plan under part D:

(A)

Prompt payment

(B)

Submission of claims by pharmacies located in or contracting with long-term care facilities

(C)

Regular update of prescription drug pricing standard

(D)

Suspension of payments pending investigation of credible allegations of fraud by pharmacies

(E)

Provision of information related to maximum fair prices

(g)

Intermediate sanctions

(1)

In general

If the Secretary determines that a Medicare+Choice organization with a contract under this section—

(A)

fails substantially to provide medically necessary items and services that are required (under law or under the contract) to be provided to an individual covered under the contract, if the failure has adversely affected (or has substantial likelihood of adversely affecting) the individual;

(B)

imposes premiums on individuals enrolled under this part in excess of the amount of the Medicare+Choice monthly basic and supplemental beneficiary premiums permitted under section 1395w–24 of this title;

(C)

acts to expel or to refuse to re-enroll an individual in violation of the provisions of this part;

(D)

engages in any practice that would reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by this part) by eligible individuals with the organization whose medical condition or history indicates a need for substantial future medical services;

(E)

misrepresents or falsifies information that is furnished—

(i)

to the Secretary under this part, or

(ii)

to an individual or to any other entity under this part;

(F)

fails to comply with the applicable requirements of section 1395w–22(j)(3) or 1395w–22(k)(2)(A)(ii) of this title;

(G)

employs or contracts with any individual or entity that is excluded from participation under this subchapter under section 1320a–7 or 1320a–7a of this title for the provision of health care, utilization review, medical social work, or administrative services or employs or contracts with any entity for the provision (directly or indirectly) through such an excluded individual or entity of such services;

(H)

except as provided under subparagraph (C) or (D) of section 1395w–101(b)(1) of this title, enrolls an individual in any plan under this part without the prior consent of the individual or the designee of the individual;

(I)

transfers an individual enrolled under this part from one plan to another without the prior consent of the individual or the designee of the individual or solely for the purpose of earning a commission;

(J)

fails to comply with marketing restrictions described in subsections (h) and (j) of section 1395w–21 of this title or applicable implementing regulations or guidance; or

(K)

employs or contracts with any individual or entity who engages in the conduct described in subparagraphs (A) through (J) of this paragraph;

the Secretary may provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph (2). The Secretary may provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph (2), if the Secretary determines that any employee or agent of such organization, or any provider or supplier who contracts with such organization, has engaged in any conduct described in subparagraphs (A) through (K) of this paragraph.

(2)

Remedies

The remedies described in this paragraph are—

(A)

civil money penalties of not more than $25,000 for each determination under paragraph (1) or, with respect to a determination under subparagraph (D) or (E)(i) of such paragraph, of not more than $100,000 for each such determination, except with respect to a determination under subparagraph (E),1

 So in original. Probably means subpar. (E) of par. (1).

an assessment of not more than the amount claimed by such plan or plan sponsor based upon the misrepresentation or falsified information involved, plus, with respect to a determination under paragraph (1)(B), double the excess amount charged in violation of such paragraph (and the excess amount charged shall be deducted from the penalty and returned to the individual concerned), and plus, with respect to a determination under paragraph (1)(D), $15,000 for each individual not enrolled as a result of the practice involved,

(B)

suspension of enrollment of individuals under this part after the date the Secretary notifies the organization of a determination under paragraph (1) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur, or

(C)

suspension of payment to the organization under this part for individuals enrolled after the date the Secretary notifies the organization of a determination under paragraph (1) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur.

(3)

Other intermediate sanctions

In the case of a Medicare+Choice organization for which the Secretary makes a determination under subsection (c)(2) the basis of which is not described in paragraph (1), the Secretary may apply the following intermediate sanctions:

(A)

Civil money penalties of not more than $25,000 for each determination under subsection (c)(2) if the deficiency that is the basis of the determination has directly adversely affected (or has the substantial likelihood of adversely affecting) an individual covered under the organization’s contract.

(B)

Civil money penalties of not more than $10,000 for each week beginning after the initiation of civil money penalty procedures by the Secretary during which the deficiency that is the basis of a determination under subsection (c)(2) exists.

(C)

Suspension of enrollment of individuals under this part after the date the Secretary notifies the organization of a determination under subsection (c)(2) and until the Secretary is satisfied that the deficiency that is the basis for the determination has been corrected and is not likely to recur.

(D)

Civil monetary penalties of not more than $100,000, or such higher amount as the Secretary may establish by regulation, where the finding under subsection (c)(2)(A) is based on the organization’s termination of its contract under this section other than at a time and in a manner provided for under subsection (a).

(4)

Civil money penalties

(h)

Procedures for termination

(1)

In general

The Secretary may terminate a contract with a Medicare+Choice organization under this section in accordance with formal investigation and compliance procedures established by the Secretary under which—

(A)

the Secretary provides the organization with the reasonable opportunity to develop and implement a corrective action plan to correct the deficiencies that were the basis of the Secretary’s determination under subsection (c)(2); and

(B)

the Secretary provides the organization with reasonable notice and opportunity for hearing (including the right to appeal an initial decision) before terminating the contract.

(2)

Exception for imminent and serious risk to health

(3)

Delay in contract termination authority for plans failing to achieve minimum quality rating

(i)

Medicare+Choice program compatibility with employer or union group health plans

(1)

Contracts with MA organizations

(2)

Employer sponsored MA plans

(Aug. 14, 1935, ch. 531, title XVIII, § 1857, as added Pub. L. 105–33, title IV, § 4001, Aug. 5, 1997, 111 Stat. 319; amended Pub. L. 106–113, div. B, § 1000(a)(6) [title V, §§ 513(a), (b)(1), 522(a)], Nov. 29, 1999, 113 Stat. 1536, 1501A–383, 1501A–387; Pub. L. 106–554, § 1(a)(6) [title VI, §§ 617(a), 623(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–561, 2763A–566; Pub. L. 108–173, title II, §§ 222(j), (k), (l)(3)(C), 237(c), title IX, § 900(e)(1)(I), Dec. 8, 2003, 117 Stat. 2205, 2207, 2213, 2372; Pub. L. 110–275, title I, §§ 164(d)(2), 171(b), 172(a)(2), 173(b), July 15, 2008, 122 Stat. 2574, 2580, 2581; Pub. L. 111–148, title VI, § 6408(b), Mar. 23, 2010, 124 Stat. 771; Pub. L. 111–152, title I, § 1103, Mar. 30, 2010, 124 Stat. 1047; Pub. L. 114–255, div. C, title XVII, § 17001(b), Dec. 13, 2016, 130 Stat. 1330; Pub. L. 115–271, title II, § 2008(b), title VI, § 6063(b), Oct. 24, 2018, 132 Stat. 3931, 3988; Pub. L. 117–169, title I, § 11001(b)(1)(F)(ii), Aug. 16, 2022, 136 Stat. 1853.)

cite as: 42 USC 1395w-27