42 USC 1395cc-2 - Provisions for administration of demonstration program

U.S Code last checked for updates: Nov 22, 2024

§ 1395cc–2.

Provisions for administration of demonstration program

(a)

General administrative authority

(1)

Beneficiary eligibility

Except as otherwise provided by the Secretary, an individual shall only be eligible to receive benefits under the program under section 1395cc–1 of this title (in this section referred to as the “demonstration program”) if such individual—

(A)

is enrolled under the program under part B and entitled to benefits under part A; and

(B)

is not enrolled in a Medicare+Choice plan under part C, an eligible organization under a contract under section 1395mm of this title (or a similar organization operating under a demonstration project authority), an organization with an agreement under section 1395l(a)(1)(A) of this title, or a PACE program under section 1395eee of this title.

(2)

Secretary’s discretion as to scope of program

The Secretary may limit the implementation of the demonstration program to—

(A)

a geographic area (or areas) that the Secretary designates for purposes of the program, based upon such criteria as the Secretary finds appropriate;

(B)

a subgroup (or subgroups) of beneficiaries or individuals and entities furnishing items or services (otherwise eligible to participate in the program), selected on the basis of the number of such participants that the Secretary finds consistent with the effective and efficient implementation of the program;

(C)

an element (or elements) of the program that the Secretary determines to be suitable for implementation; or

(D)

any combination of any of the limits described in subparagraphs (A) through (C).

(3)

Voluntary receipt of items and services

(4)

Agreements

(5)

Program standards and criteria

(6)

Administrative review of decisions affecting individuals and entities furnishing services

(7)

Secretary’s review of marketing materials

(8)

Payment in full

(A)

In general

(B)

Collection of deductibles and coinsurance

(b)

Contracts for program administration

(1)

In general

(2)

Scope of program administrator contracts

(3)

Eligible contractors

The Secretary may contract for the administration of the program with—

(A)

an entity that, under a contract under section 1395h or 1395u of this title, determines the amount of and makes payments for health care items and services furnished under this subchapter; or

(B)

any other entity with substantial experience in managing the type of program concerned.

(4)

Contract award, duration, and renewal

(A)

In general

(B)

Noncompetitive award and renewal for entities administering part A or part B payments

(5)

Applicability of Federal Acquisition Regulation

(6)

Performance standards

(7)

Functions of program administrator

A program administrator shall perform any or all of the following functions, as specified by the Secretary:

(A)

Agreements with entities furnishing health care items and services

(B)

Establishment of payment rates

(C)

Payment of claims or fees

(D)

Payment of bonuses

(E)

Oversight

(F)

Administrative review

(G)

Review of marketing materials

(H)

Additional functions

(8)

Limitation of liability

(9)

Information sharing

(c)

Rules applicable to both program agreements and program administration contracts

(1)

Records, reports, and audits

(2)

Bonuses

Notwithstanding any other provision of law, but subject to subparagraph (B)(ii), the Secretary may make bonus payments under the demonstration program from the Federal Health Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund in amounts that do not exceed the amounts authorized under the program in accordance with the following:

(A)

Payments to program administrators

(B)

Payments to entities furnishing services

(i)

In general

(ii)

Limitations

(3)

Antidiscrimination limitation

(d)

Limitations on judicial review

The following actions and determinations with respect to the demonstration program shall not be subject to review by a judicial or administrative tribunal:

(1)

Limiting the implementation of the program under subsection (a)(2).

(2)

Establishment of program participation standards under subsection (a)(5) or the denial or termination of, or refusal to renew, an agreement with an entity to provide health care items and services under the program.

(3)

Establishment of program administration contract performance standards under subsection (b)(6), the refusal to renew a program administration contract, or the noncompetitive award or renewal of a program administration contract under subsection (b)(4)(B).

(4)

Establishment of payment rates, through negotiation or otherwise, under a program agreement or a program administration contract.

(5)

A determination with respect to the program (where specifically authorized by the program authority or by subsection (c)(2))—

(A)

as to whether cost savings have been achieved, and the amount of savings; or

(B)

as to whether, to whom, and in what amounts bonuses will be paid.

(e)

Application limited to parts A and B

(f)

Reports to Congress

(Aug. 14, 1935, ch. 531, title XVIII, § 1866B, as added Pub. L. 106–554, § 1(a)(6) [title IV, § 412(a)], Dec. 21, 2000, 114 Stat. 2763, 2763A–511; amended Pub. L. 108–173, title VII, § 736(c)(5), Dec. 8, 2003, 117 Stat. 2356.)

cite as: 42 USC 1395cc-2