The Children's Health and Medicare Protection Act of 2007 : section-by-section analysis / prepared by Committees on Ways and Means and Energy and Commerce

2007·27.9 MB·English

by  United States. Congress. House. Committee on Ways and Means

THECHILDREN'SHEALTHANDMEDICAREPROTECTIONACTOF2007
SECTION-BY-SECTIONANALYSIS
TITLEL CHILDREN'SHEALTH
SubtitleA—Funding
Sec.100.Purpose. EstablishesthepurposeofTitleIistostabilizefundingundertitle
XXIandXIXinordertoenrollallsixmillionchildrenwhoareeligiblebutnotenrolled
forcoveragetoday.
Sec. 101.EstablishmentofnewbaseCHIPallotments. EstablishesanewState-specific
federalallotmentsforCHIP.AllotmentswouldbethegreaterofaState'sprojectionsfor
FY08asreportedinMayof2007ortheState'sFY07allotmentincreasedbychild
populationgrowthandpercapitanationalhealthcareexpendituregrowth.ForStates
thatexperienceashortfallandwhohaveenrolledchildrenwhoareeligiblebutnot
currentlyenrolledinCHIP,thissectionalsoprovidesapaymentequaltotheState's
averagepercapitafederalexpenditureforachild.
Sec.102.2-yearinitialavailabilityofSCHIPallotments. Providesstatestwoyearsto
spendthefederalCHIPallotmentforanygivenyear.
Sec. 103.RedistributionofunusedallotmentstoaddressStatefundingshortfalls.
EstablishesasystemforredistributinganyStateallotmentsunspentaftertwoyears.
Themethodforredistribution(evenlydistributedtotheshortfallstates)isthesameas
usedforpreviousshortfalladjustmentsenactedbyCongress.
Sec.104.ExtensionofoptionforqualifyingStates. Permanentlyextendstheoption
for"qualifyingstates" touseaportionoftheirCHIPallotmentforchildrencovered
throughMedicaidandincreasestheamountoftheallotmentthatcanbespentonsuch
coverage.
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SubtitleB ImprovingEnrollmentofEligibleChildren
Sec. 111. SCHIPperformancebonuspaymenttooffsetadditionalenrollmentcosts
resultingfromoutreach,enrollment,andretentionefforts. Providesaperformance
bonuspaymentforStatesthatenrollchildrenabovetheirbaselineandadoptfiveof
sevenoutreachandenrollmentbestpractices: 12-monthcontinuouseligibility;
administrativeverificationofassets;eliminationofthein-personinterviewrequirement;
useofajointapplicationforMedicaidandCHIP;automaticrenewal;presumptive
eligibility;expresslaneeligibility.Theperformancebonusisavailableforenrollmentof
childrenwhoarecurrentlyeligibleforCHIPorMedicaidtodaybutarenottoday
enrolled.
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Sec. 112. Stateoptiontorelyonfindingsfromanexpresslaneagencytoconduct
simplifiedeligibilitydeterminations. ProvidesStatesanewtoolforoutreach,called
ExpressLaneEligibility(ELE).StatesthatelecttheELEoptioncoulduseafindingfrom
anELEagencytoexpediteeligibilitydeterminationsbyCHIPorMedicaid.
Sec.113.ApplicationofMedicaidoutreachprocedurestoallchildrenandpregnant
women. AllowsStatestoapplyoutreachprocedurestoallchildrenandpregnant
women.
Sec.114.Encouragingculturallyappropriateenrollmentandretentionpractices.
ProvidesadditionalfederalfundingforculturallyappropriateeiTrollmentandretention
activities.
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SubtitleC Coverage
Sec.121.Ensuringchild-centeredcoverage. ImprovesCHIPcoveragebyaddinga
guaranteeddentalbenefitforchildren.Itwouldrequireparityformentalhealth
coverageunderbenchmarkplansandguaranteeaccesstofederallyqualifiedhealth
centers(FQHCs)andruralhealthcenters(RHCs).TheFQHC'sandRHC'swouldalso
bepaidunderaprospectivepaymentsystem.Theprovisionalsoclarifiesthatschool
clinicservicesmaybecoveredunderCHIP.
Sec. 122. Improvingbenchmarkcoverageoptions. EnsuresthatSecretary-approved
benchmarkcoverageisnolessprotectiveforchildrenthanthecoverageofferedinother
benchmarkoptions.Thissectionalsoclarifiesthatthestateemployeecoverage
benchmarkoptionistheoptionmostfrequentlyselectedbyemployeesseekingfamily
coverage.
Sec.123.Premiumgraceperiod. Grantsfamiliesa30-daygraceperiodforpremium
paymentunderCHIPbeforeterminationofachild'scoverage.
SubtitleD—Populations
Sec.131.OptionalcoverageofolderchildrenunderMedicaidandSCRIP. Grants
StatestheoptiontocoverchildrenwhootherwiseageoutofCHIPorMedicaid.States
thatelectedthisoptioncouldcoverchildrenaboveexistingeligibilitylevels,through
age24.
Sec.132.OptionalcoverageoflegalimmigrantsundertheMedicaidprogram
andSCHIP. ProvidesStatestheoptiontocoverlegalimmigrantchildrenandlegal
immigrantpregnantwomeninCHIPorMedicaid.AStatemayonlycoverthese
individualsinCHIPiftheStatealsoelectstocoversuchindividualsinMedicaid.
Sec. 133.Stateoptiontoexpandoraddcoverageofcertainpregnantwomenunder
CHIP. ProvidesaneweligibilityoptioninCHIPforStatestocoverpregnantwomen.A
StatemayexercisethisoptioniftheStatecoverspregnantwomenunderMedicaidto
185% ofthefederalpovertylevel, coverschildreninfamilieswithincomesupto200%
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ofthefederalpovertylevel,and doesnotimposeawaitinglistforenrollmentof
childrenunderCHIP.Statesthatpreviouslycoveredpregnantwomenathigherincome
levelsthroughMedicaidmayuseupto30percentoftheirCHIPallotmentforsuch
coverage.Thissectionalsoautomaticallyenrollschildrenborntomotherscovered
underCHIPorMedicaidincoverageuponbirthandallowsentitiesthatconduct
presumptiveeligibilityforchildrentodosoforpregnantwomen.
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SubtitleE Access
Sec.141. Children'sAccessPaymentandEquity(CAPE) Commission. Createsanew
federalCommission, modeledaftertheMedicarePaymentAdvisoryCommission
(MedPAC),tomonitoraccessandqualityofcareforchildrenunderCHIPandMedicaid
aswellasadequacyofproviderpayments, includingsafetynetproviders.
Sec.142.ModelofInterstatecoordinatedenrollmentandcoverageprocess.Directsthe
GovernmentAccountabilityOffice(GAO)toworkwithstakeholderstodevelopmodel
practicestofacilitateenrollmentofchildrenwholiveinfamiliesthatmovefrequently
aroundtheUnitedStates.
Sec.143.Medicaidcitizenshipdocumentationrequirements. Amendsthe
requirementsfordocumentingcitizenshipandidentitytoallowindividualsa
reasonableperiodoftimetogathernecessaryinformation, allownewbornstomeet
requirementsmoreeasily, andallowadditionaltribalmembershipdocumentstobe
usedassatisfactoryevidenceofcitizenshipornationality.Thissectionalsoallowsstates
theoptionofreturningtopre-July 1,2006documentationrequirementsforchildren,so
longastheStatesubmitstoanauditofasampleofcasestodemonstratecompliance.
Sec.144.GAOstudyofaccesstodentalservicesforchildren. Providesforastudyby
theGovernmentAccountabilityOfficeonaccesstodentalservicesinunderservedareas.
Sec.145.Prohibitinginitiationofnewhealthopportunityaccountdemonstration
programs. Prohibitsadditionalhealthopportunityaccountdemonstrations.
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SubtitleF QualityandProgramIntegrity
Sec.151.Pediatrichealthqualitymeasurementprogram. Establishesapediatrichealth
carequalitymeasurementprogramtodevelopandimplementmeasuresofpediatric
clinicalqualityandmeasuresofoverallprogramquality.Thesemeasureswill
specificallyexaminedisparitiesincarebasedonage,race,ethnicity,andgeography.
Sec.152.ApplicationofcertainmanagedcarequalitysafeguardstoCHIP. Applies
managedcarequalityprotectionssuchasthequalityassurancestandards,protections
againstfraudandabuse,andthe"prudentlayperson" standardforaccesstoemergency
caretomanagedcareorganizationsinCHIP.
Sec.153. UpdatedFederalEvaluationofCHIP.Providesforanewfederalevaluation
oftheCHIPprogramin2010,modeledaftertheinitialevaluationcompletedin2005.
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Sec, 154. ReferencestotitleXXL Repealssection704oftheMedicare,Medicaid,and
SCRIPBalancedBudgetRefinementActof1999.
Sec.155. Relianceonlaw;exceptionforStatelegislation.Allowsforgood-faith
implementationofprovisionsbyStatespriortoCMSregulatoryactionandallows
flexibilityineffectivedatesforStateswhichneedlegislationtocomplywiththe
provisionsofthistitleortitleVIII.
TITLEIL MEDICAREBENEFICIARYIMPROVEMENTS
SubtitleA -ImprovementsinBenefits
Sec.201. Coverageandwaiverofcost-sharingforpreventiveservices. Effective
January 1, 2008,allowstheSecretaryofHealthandHumanServicestoaddnewbenefits
forpreventiveitemsandservices,includingmentalhealthservices, thatarereasonable
andnecessaryforthepreventionorearlydetectionofanillnessordisability. Requires
theSecretarytotakeintoaccountevidence-basedrecommendationsoftheUnited
StatesPreventiveServicesTaskForceandotherappropriateorganizationswhen
creatingnewbenefits. Eliminatesco-insuranceforandexemptsfromdeductiblecurrent
preventivebenefitsandfuturepreventivebenefitsaddedthroughthisprocess.
Requiresnewpreventivebenefitstobeincludedaspartoftheinitial"Welcometo
Medicare" physical.
Sec.202. Waiverofdeductibleforcolorectalcancerscreeningtestsregardlessof
coding,subsequentdiagnosis,orancillarytissueremoval. EffectiveJanuary 1,2008,
clarifiesthatthedeductibleiswaivedforascreeningcolonoscopyevenifadiagnosisis
establishedasaresultofatestortissueisremovedduringtheprocedure.
Sec.203. Parityformentalhealthcoinsurance. Reducescoinsuranceforoutpatient
mentalhealthservicesbyfivepercentagepointsannuallyfrom50percentto20percent
by2012.
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SubtitleB Improving,Clarifying,andSimplifying
FinancialAssistanceforLow-IncomeMedicareBeneficiaries
Sec.211. ImprovingassetstestsforMedicareSavingsProgramandLow-Income
Subsidyprogram. Increasestheamountofallowableresourcesto$17,000foran
individualand$34,000foracoupleinorderto qualifyforassistancewithMedicarePart
BandDcosts. Startingin2010, thelimitisincreasedannuallyby$1,000perindividual
and$2,000percouple.
Sec.212. MakingQIprogrampermanentandexpandingeligibility. Makespermanent
theQualifiedIndividual(QI)programthatprovidesassistancewithpremiumsfor
certainlow-incomebeneficiaries,whichotherwiseexpiresonSeptember30,2007.Raises
theQIincomelevelto 150% ofthefederalpovertylevel,or$15,315foranindividualin
2007.
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Sec.213.Eliminatingbarrierstoenrollment. Providesforadministrativeverification
ofincomeandresourcesforindividualsundertheLow-IncomeSubsidy(LIS)program
aswellasautomaticrenewalwithouttheneedtoreapply. DirectstheSecretaryof
HealthandHumanServicestotakeallreasonablestepstoencourageStatestoadopt
theseenrollmentsimplificationsintheMedicareSavingsPrograms(MSP).
DirectstheCommissionerofSocialSecuritytoprovideapplicationsforMSPandLISto
individualsapplyingforMedicarebenefitsandtoprovideassistanceincompleting
suchapplicationsattherequestofthebeneficiary. RequirestheCommissionerto
forwardcompletedMSPapplicationstoStatesforeligibilitydeterminations. Requires
theSecretaryofHealthandHumanServicestotranslatetheexistingsimplifiedMSP
formintoatleastthetenlanguagesmostoftenusedbyindividualsapplyingforbenefits
undertitleIIortitleXVIII. AllowstheCommissionerofSocialSecuritytoobtaindata
fromIRStoidentifybeneficiariespotentiallyeligiblefortheLIS.
Sec.214.Eliminatingapplicationofestaterecovery. Eliminatestherequirementthat
StatesrecovercostsfromtheestateofindividualsreceivingassistancewithPartBcosts
beginningin2008.
Sec.215.EliminationofpartDcost-sharingforcertainnon-institutionalizedfull-
benefitdualeligibleindividuals. Ensuresthatdualeligiblebeneficiariesreceivingcare
throughahome-andcommunity-basedcarewaiveraretreatedthesamewithrespect
tocostsharingunderPartDasbeneficiarieswhoareinnursinghomes.Thisensuresthe
lowestincomeMedicarebeneficiariescanchoosetoreceivecareintheleastrestrictive
communitysettingwithoutpenalty.
Sec.216.Exemptionsfromincomeandresourcesfordeterminationofeligibilityfor
low-incomesubsidy. Exemptsthebalanceofapensionandretirementplanandthe
valueofalifeinsurancepolicyfromLISresourcedeterminations.Italsoexemptsin
kindsupportandmaintenance(e.g., assistanceprovidedbyafamilymemberor
church)fromLISincomedeterminations.Theprotectionsbeginin2009.
Sec.217. Cost-sharingprotectionsforlow-incomesubsidy-eligibleindividuals. Caps
out-of-pocketspendingunderPartDto2.5percentofincomeannuallyforthelowest
incomeMedicarebeneficiaries($15,315). Theseprotectionsbeginin2009.
Sec.218. Intelligentassignmentinenrollment. EnsuresthelowestincomeMedicare
beneficiarieswhoareautomaticallyassignedtoaPartDplan,areassignedtoaplan
that: (1)covers95percentofthe100branddrugsmostcommonlyusedbyMedicare
beneficiaries;(2)covers95percentofthe100genericdrugsmostcommonlyusedby
Medicarebeneficiaries;(3)providespharmacyaccessthatexceedsminimumstandards,
includingaccessinareaswherelowincomebeneficiariesreside;and(4)hasatotalcost
amongthelowest25*percentileofplanswherethebenefidaryresides.Thisprovision
takeseffectin2009.
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SubtitleC—PartDBeneficiaryImprovements
Sec.221. IncludingcostsincurredbyAIDSdrugassistanceprogramsandIndian
HealthServiceinprovidingprescriptiondrugstowardtheannual outofpocket
thresholdunderPartD. AllowscostsforPartDprescriptionmedicinespaidbythe
IndianHealthService(IHS)oranAIDSDrugAssistanceProgram(ADAP)tocount
towardabeneficiary'stotalout-of-pocketPartDspendingbeginningin2009for
purposesoffillingthedonuthole.
Sec.222.Permittingmid-yearchangesinenrollmentforformularychangesadversely
impactanenrollee. Allowsabeneficiarytochangetoanewplaniftheirplanhasa
mid-yearmaterialchangeintheformularythatreducesaccesstotheirprescribeddrug
(unlesssuchchangewasrequiredforsafetyreasons).Thisprovisiontakeseffectin2009.
Sec.223. Removal ofexclusionofbenzodiazepinesfromrequiredcoverageunderthe
Medicareprescriptiondrugprogram. AllowsPartDplanstocoverbenzodiazepines,
whicharecommonlyusedbyindividualswithmentalillness.Thisprovisiontakeseffect
in2009.
Sec.224.PermittingupdatingdrugcompendiaunderpartDusingpartBupdate
process. AllowstheSecretarytoupdatecompendiausfedunderPartDusingaprocess
similartotheoneinplaceunderPartB.
Sec.225. Codificationofspecialprotectionsforsixprotecteddrugclassifications.
CodifiestheSecretary'sguidancerelatingtocoverageofthe"sixprotectedclasses" of
drugsunderPartD,anti-convulsants, anti-neoplastics,anti-retrovirals, anti-depressants,
anti-psychotics,andimmunosuppressants.Italsoclarifiesthatplansmayonlyuseprior-
authorizationorsteptherapywhenapprovedbytheSecretary.
Sec.226.EliminationofMedicarepartD lateenrollmentpenaltiespaidbylow-
incomesubsidy-eligibleindividualsforperiods. EliminatesthePartDlateenrollment
penaltyforlow-incomesubsidyeligibleindividualstoensurePartDcoverageis
availablewithoutpenalty.
Sec.227,Specialenrollmentperiodforsubsidyeligibleindividuals. Providesfora
specialenrollmentperiodforLISsubsidy-eligibleindividuals, allowingupto90days
afternotificationofLISstatus, toselectaPartDplanorMedicareAdvantageplanthat
coversprescriptiondrugs.Thisprovisiontakeseffectin2008.
SubtitleD—ReducingHealthDisparities
Sec.231.Medicaredataonrace,ethnicity,andprimary language.Requiresthe
Secretarytocollect, analyze, andreportdataonrace,ethnicity, andprimarylanguage
ofMedicarebeneficiaries.
Sec.232.EnsuringeffectivecommunicationinMedicare.RequirestheSecretaryto
conductastudyonMedicarepaymentsforlanguageservices, andprovidesfor
additionalenforcement.
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Sec.233.DemonstrationtopromoteaccessforMedicarebeneficiarieswithlimited
EnglishproficiencybyprovidingMedicarereimbursementforculturallyand
linguisticallyappropriateservices. RequiresCMStoconductademonstrationofthe
effectofMedicarereimbursementforculturallyandlinguisticallyappropriateservices.
Sec.234.Demonstrationtoimprovecaretopreviouslyuninsured. RequiresCMSto
conductademonstrationtoimproveoutreachtoandsupportforMedicarebeneficiaries
whowerepreviouslyuninsured.
Sec.235. OfficeoftheInspectorGeneral reportoncompliancewithandenforcement
ofnationalstandardsonculturallyandlinguisticallyappropriateservices(CLAS)in
Medicare. RequirestheOfficeoftheInspectorGeneraltostudyandreportonthe
extenttowhichMedicareprovidersarecomplyingwithCLASstandards,andtheextent
towhichnon-complianceisbeingenforced.
Sec.236. lOMReportonimpactoflanguageaccessservices.RequirestheInstituteof
Medidnetoconductastudyandissueareportontheeffectoflanguageaccessservices
onaccesstoandqualityofcare.
Sec.237.Definitions. Definestermsusedinthissection.
TITLEIII--MEDICAREPHYSICIANPAYMENTREFORM
Sec.301.Establishmentofseparatetargetgrowthratesforservicecategories.Provides
fora0.5percentupdatein2008and2009. ReplacestheSustainableGrowthRate(SGR)
methodologywithasystemofseparateupdatesforsixcategoriesofphysicianservices
withintheMedicarefeeschedule: PrimaryandPreventiveServices,OtherEvaluation
andManagementServices,MajorProcedures,AnesthesiaServices,ImagingServices,
MinorProceduresandOtherServices. PrimaryCareandPreventiveServicesCategory
annualallowedgrowthwouldequalgrowthinthegrossdomesticproduct(GDP)plus
3percent;annualallowedgrowthforotherservicecategorieswouldequaltheGDP
growth. Futurefeescheduleupdateswouldtakeintoconsiderationtheprior
"overhang" ofaccumulatedexcessexpendituresundertheSGRsystem,butwouldnot
incorporategrowthofexpendituresforclinicaldiagnosticlaboratorytestsordrugsand
wouldincludenationalcoveragedeterminationsasallowedgrowth. Requiresthe
Secretarytoannuallyreportgrowthofexpendituresforclinicaldiagnosticlaboratory
testsordrugsinthephysicianfeescheduleproposedrule,includinganalysisofreasons
forsuchgrowthandrecommendationsforaddressingit.
Sec.302, ImprovingaccuracyofrelativevaluesundertheMedicarePhysicianFee
Schedule. Establishesanexpertpaneltoidentifyphysicians' servicesforwhichthe
relativevalueispotentiallymisvalued.TheSecretarywouldalsoidentifyphysician
servicesgrowingatanunusuallyhighannualrateandwouldhavetheauthorityto
reducetheworkvalueofspecificphysicianservicesafterconsultationwiththeexpert
panelandconsiderationofevidencesupportingtheclinicalappropriatenessofthe
observedrapidgrowth.
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Sec.303.PhysicianFeedbackmechanismonpracticepatterns.RequirestheSecretary
toimplementasystemofconfidentialfeedbacktophysiciansintheMedicareprogram
onhowtheirpracticepatternscomparetootherphysiciansbothinthesamelocalityas
wellasnationally.
Sec.304.Paymentsforefficientphysicians. Providesa5percentbonusforMedicare
physicianspracticingincountiesinthelowest5thpercentileofpercapitaspending.
Sec.305. RecommendationsonrefiningthePhysicianFeeSchedule.RequiresGAOto
conductananalysisofcodespaidundertheMedicarephysicianfeescheduleto
determinewhetherthecodesforproceduresthatarecommonlyfurnishedtogether
shouldbecombinedand/orpaymentsadjusted;GAOwouldalsoanalyzetheMedicare
physicianfeescheduletoidentifyopportunitiesforincreaseduseof "bundled"
paymentmethodologies.
Sec.306. ImprovedandexpandedMedicalHomeDemonstrationProject.Initiatesa
nationwideprojectinvolvingupto500medicalpractices,especiallythoseserving
communitieswhosepopulationsareathigherriskforhealthdisparities.TheSecretary
wouldcertifypracticestobeeligibleforpaymentfor"MedicalHome" services,actively
managingandcoordinatingcareforparticipatingbeneficiaries. TheSecretarywould
alsocertifypracticesusingrobusthealthinformationtechnology(HIT)intheirmedical
homemodel,andwouldconductaseparatestudyoftheadditionalcostsandbenefitsof
the"HITenhancedmedicalhome."
Sec.307. RepealofPhysicianAssistanceandQualityInitiativeFund.Repealsthe
bonusfundforthePhysicianAssistanceandQualityInitiative,butallowstheprogram
tocontinueonavoluntarybasis.
Sec.308.AdjustmenttoMedicarepaymentlocalities. RequiresCMStorevise
paymentlocalitiesinCaliforniabyJanuary 1,2008, andinmulti-localitystatesby
January 1, 2011. ProvidesfortransitionfundingforcountiesinCaliforniathatwould
otherwiseexperiencelossesasaresultoftherevisedlocalities.
Sec.309.PaymentforImagingServices. Establishesanaccreditationprocessfor
facilitiesthatprovidediagnosticimagingservicesandrequiresthatafacilitybe
accreditedinordertoreceivereimbursementforimagingservicesfromMedicare.
RequiresCMStoincreasetheirassumptionontheamountoftimeimagingequipment
isinusefrom50percentto75percent. Requiresa50percentreductioninthetechnical
componentforimagingservicesinvolvingcontiguousbodyparts. RequiresCMSto
assumethattheinterestrateforcapitalpurchasesreflectstheprevailingrateinthe
market,butinnocasehigherthan11 percent. Disallowsglobalbilling.
Sec. 310. RepealofPhysiciansAdvisoryCouncil. RepealsthePracticingPhysicians
AdvisoryCouncil.
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TITLEIV-MEDICAREADVANTAGE REFORMS
SubtitleA- PaymentReform
Sec.401. EqualizingpaymentsbetweenMedicareAdvantageplansandfee-for-
MA
serviceMedicare. Phases-outoverpaymentsto plansoverfouryearsto100%FFS
in2011. Thephase-outofpaymentsinexcessof100% FFSwouldbeablendofthe
currentcountybenchmarksadjustedfortheapplicableyearand100% ofcountyFFS
costsintheprojectedyear. In2009,thebenchmarkswouldbeablendof2/3current
benchmarkand1/3 100%FFSinthecounty;in2010, theblendwouMlAdbe1/3current
benchmarkand2/3100%FFS. In2011,andsubsequentyears, all benchmarks
wouldbesetat100%FFScostsinthecounty.
ProvidesthatMAplansthatindicateintheirbidsthattheycannotprovideMedicare
PartAandPartBservicesforlessthan106%oofFFScostsin2009and103%o in2010may
notenrollnewbeneficiariesinthoseyears.
EliminatestheremainingauthorityforspendingfromtheregionalPPOstabilization
fundin2012and2013.
SubtitleB-BeneficiaryProtections
Sec.411. NAICdevelopmentofmarketing,advertisingandrelatedprotections.
RequeststheNationalAssociationofInsuranceCommissioners(NAIC)todevelop
modelmarketing,advertisingandrelatedbeneficiaryprotectionsforMAandPartD
plans. Requiresthemodelregulationstoincludestandardsformarketingactivities,
ensureappropriatebeneficiaryeducation,setstandardsfortrainingandcertification,
limitagentandbrokercommissionsandconductmarketconductsurveys. Increases
penaltiesforviolationsoftheseprotections.
TheNAICwouldconsultwithaworkinggroupofrepresentativesofMAplan
representatives, consumergroups. Medicarebeneficiaries,andStateHeathInsurance
Programs. ProvidesfortheNAICtopromulgatemodelregulations12monthsfrom
dateofenactment.
MA
Expandstheroleofstateoversightofagents,brokersand plans. Themodel
marketingregulationswouldbeaconditionofallplancontracts. Requiresthe
MA
Secretarytopubliclydisclose planviolationsofthemarketingandenrollment
standards.
IncreasesfundingtoStateHealthInsuranceAssistancePrograms(SHIPs).
Sec.412. Limitationonout-of-pocketcostsforindividualservices. Limitsout-of-
pocketcostsinMAplansforanyservicetonomorethantheamountofcost-sharingfor
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MA
thesameserviceinFFSMedicare. Limitsout-of-pocketcostsin plansforMedicaid
beneficiariestotheamountofcost-sharingforthesameserviceinMedicaidintheState.
MA MA
Sec.413. planenrollmentmodifications. Revises planenrollmentpracticesto
providecontinuousopenenrollmentforfullMedicaiddualeligiblesandQualified
MedicareBeneficiaries(peoplewithincomesupto 100% ofpoverty). Providesspecial
electionperiodstoadditionalbeneficiarieswithspecialhealthneeds. Extendsthe
periodthatMedicarebeneficiariesmayreturntotheirpreviousMedigapplanto24
MA
months. Prohibitsauto-enrollmentofMedicaidbeneficiariesintoa plan.
Sec.414. Informationforbeneficiariesonplanadministrativecostsandservices.
MA
Providesforeach planMedicareLossRatioandotherinformation,tobepublicly
MA
reportedinSeptemberofeachyearpriortothefall planopenenrollmentperiod.
TheMLRinformationwouldusedatacurrentlysubmittedaspartoftheMAbid
process. StandardizeddataelementsanddefinitionsforthecalculationoftheMRL
wouldbedevelopedforimplementationin2010. Plansthatdonothaveaminimum
MLRof.85beginningin2010wouldfacebenchmarkreductions,limitsonnew
MA
enrollmentand, afteryear5years,exclusionfromthe program. Providesfor
additionalMAprograminformationtoberoutinelypublished.
SubtitleC-QualityandOtherProvisions
MA
Sec.421. Requiringall planstomeetequalstandards. Equalizestheplayingfield
acrosstypesofMAplansbyrequiringPFFSandPPOplanstoreportthesamedata
reportedbyCoordinatedCarePlansforHEDIS,CAHPSandHOSqualitymeasures
beginningin2010.
Requiresemployerplanstohave90%oftheirmembersincountieswheretheMAplan
firmhasaplanavailabletolocalresidents. TheMAprovisionsoftheCHAMPAct
couldnotbewaivedforemployerplans.
Sec.422. Developingnewqualityreportingmeasuresonracialdisparities. New
HEDISmeasurestoassessdisparitiesintheamountandquantityofhealthservices
pprreovviioduesdptroacrtaicicaeloafnidsseutihnngicbimeinnnoirailtireespowrotsulodnbdeisdpearvietlioepseidn.MHAHpSlawnouselrdvirceetsutrontoits
minorities.
Sec.423. Strengtheningauditauthority. Auditswouldberequiredforriskadjustment
datainamannersimilartoauditsofotherMAplandata. ProvidesHHStheauthority
MA
necessarytoaddressdeficienciesidentifiedin planaudits.
Sec.424. ImprovingriskadjustmentforMAplans.TheadequacyoftheMArisk
adjustmentsystemwithafocusonitsaccuracyinpredictingthecostsofenrolleeswith
multiplechronicdiseaseswouldbeanalyzedbyHHSandareporttoCongress
submittedwithinoneyear.
Sec.425. Eliminatingspecialtreatmentofprivatefee-for-serviceplans. Special
featuresoftheMAprogramforPFFSplanswouldbeeliminated. Hospitals,physician
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