I

106TH CONGRESS

2D SESSION H. R. 4753

To establish a demonstration project to create Medicare Consumer Coalitions

to provide Medicare beneficiaries with accurate and understandable information with respect to managed care health benefits under the Medicare

Program and to negotiate with Medicare+Choice organizations offering

Medicare+Choice plans to improve and expand benefits under the plans.

IN THE HOUSE OF REPRESENTATIVES

JUNE 26, 2000

Mrs. KELLY introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Commerce, for a period to be subsequently determined by the Speaker, in

each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To establish a demonstration project to create Medicare Consumer Coalitions to provide Medicare beneficiaries with

accurate and understandable information with respect

to managed care health benefits under the Medicare Program and to negotiate with Medicare+Choice organizations offering Medicare+Choice plans to improve and

expand benefits under the plans.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE.

2 This Act may be cited as the ‘‘Seniors Health Care

3 Empowerment Act of 2000’’.

4 SEC. 2. MEDICARE CONSUMER COALITION DEMONSTRA5 TION PROJECTS.

6 (a) ESTABLISHMENT OF PROJECTS.—The Secretary

7 of Health and Human Services (hereinafter in this section

8 referred to as the ‘‘Secretary’’) shall establish demonstra9 tion projects (hereinafter in this section referred to as the

10 ‘‘projects’’) under which a Medicare Consumer Coalition

11 (hereinafter in this section referred to as an ‘‘MCC’’) is

12 formed to carry out the following functions:

13 (1) To conduct programs to prepare, make

14 available, and disseminate to Medicare beneficiaries

15 comprehensive and understandable information (de16 scribed in subsection (f)) with respect to enrollment

17 in the following:

18 (A) A Medicare+Choice plan, as defined in

19 subsection (j)(1).

20 (B) A medigap plan, as defined in sub21 section (j)(2).

22 (2) For the purpose of improving benefits and

23 reducing premiums for members of the MCC, to ne24 gotiate with Medicare+Choice plans and, to the ex25 tent practicable, medigap plans.
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1 (b) MCC DESCRIBED.—For purposes of this section,

2 an MCC is a legal entity that meets the following require3 ments:

4 (1) ORGANIZATION AND OPERATION.—The enti5 ty is a nonprofit organization that is—

6 (A) organized and maintained in good

7 faith, with a constitution and bylaws specifically

8 stating its purpose and providing for periodic

9 meetings on at least an annual basis,

10 (B) established as a permanent entity

11 which receives the active support of its mem12 bers and, subject to paragraph (3), collects

13 from its members on a periodic basis dues or

14 payments necessary to maintain eligibility for

15 membership in the sponsor, and

16 (C) is operated under the direction of a

17 board of directors the members of which are

18 Medicare beneficiaries, such board comprised of

19 a majority of such beneficiaries who live in the

20 Medicare market area designated under sub21 section (c) in which the MCC carries out its

22 functions and providers of services.

23 (2) OPEN MEMBERSHIP.—The entity makes all

24 Medicare beneficiaries who live in the Medicare mar25 ket area eligible to enroll in the MCC.
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1 (3) FEES.—

2 (A) IN GENERAL.—Subject to subpara3 graph (B), the entity may charge Medicare

4 beneficiaries a nominal enrollment fee, in no

5 case to exceed $25.

6 (B) EXCEPTION.—No enrollment fee may

7 be charged in the case of the following qualified

8 Medicare beneficiaries:

9 (i) Individuals described in section

10 1905(p)(1) of the Social Security Act (42

11 U.S.C. 1396d(p)(1)) (QMBs).

12 (ii) Individuals described in section

13 1902(a)(10)(E)(iii) of such Act (42 U.S.C.

14 1396a(a)(10)(E)(iii)) (specified low-income

15 Medicare beneficiaries (SLMBs).

16 (iii) Individuals described in section

17 1902(a)(10)(E)(iv) of such Act (42 U.S.C.

18 1396a(a)(10)(E)(iv)) (qualifying individ19 uals (QIs)).

20 (4) AUTHORITY TO ENTER INTO CONTRACTS TO

21 CARRY OUT ADMINISTRATIVE FUNCTIONS.—The en22 tity may enter into contracts with private agencies

23 or persons to carry out administrative functions of

24 the entity.
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1 (c) DESIGNATION OF MEDICARE MARKET AREAS

2 COVERED BY PROJECTS.—

3 (1) IN GENERAL.—The Secretary shall des4 ignate areas in which the project under this section

5 is conducted as Medicare market areas.

6 (2) DESIGNATION OF 6 AREAS.—

7 (A) IN GENERAL.—The Secretary, con8 sistent with subparagraph (B), shall designate

9 6 specific areas as Medicare market areas. Such

10 designations shall be made in a manner so as

11 to ensure that enrollment under the projects

12 will begin on January 1, 2002.

13 (B) MINIMUM AREA.—A Medicare market

14 area shall be comprised of at least one entire

15 county or equivalent area (as determined by the

16 Secretary). In the case of an MCC that serves

17 more than one State, such equivalent area may

18 be include areas in two or more contiguous

19 States.

20 (d) PROJECT IMPLEMENTATION.—For each Medicare

21 market area, the Secretary shall—

22 (1) develop and disseminate a request for pro23 posals for the establishment of MCCs in the 6 des24 ignated Medicare market areas, and
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1 (2) structure the method for selecting a coali2 tion in such area, with a preference for broad par3 ticipation by nonprofit community organizations

4 with experience representing and providing informa5 tion to Medicare beneficiaries in the area.

6 (e) MONITORING AND REPORT.—

7 (1) MONITORING.—The Secretary shall closely

8 monitor and analyze the impact of the project in the

9 Medicare market areas on the price and quality of,

10 and access to, Medicare covered services, choice of

11 Medicare+Choice plans and medigap plans, changes

12 in enrollment, and other relevant factors.

13 (2) REPORT.—Not later than December 31,

14 2005, the Secretary shall submit to Congress a re15 port on the progress under the project under this

16 section, including a comparison of the matters mon17 itored under paragraph (1) and subsection (g)(4)

18 among the different Medicare market areas. The re19 port may include any legislative recommendations

20 for extending the project to all Medicare bene21 ficiaries.

22 (f) INFORMATION.—

23 (1) CONTENTS.—The information described in

24 subsection (a)(1) shall include at least a comparison

25 of contracts and policies available under
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1 Medicare+Choice plans and medigap plans, includ2 ing a comparison of the benefits, quality and per3 formance, costs to enrollees, results of consumer sat4 isfaction surveys on such contracts and policies, and

5 such additional information as the Secretary may

6 prescribe.

7 (2) INFORMATION STANDARDS.—The Secretary

8 shall develop standards and criteria to ensure that

9 the information provided to Medicare beneficiaries

10 under the projects is complete, accurate, and uni11 form.

12 (3) REVIEW OF INFORMATION.—The Secretary

13 may prescribe the procedures and conditions under

14 which an MCC may furnish information to Medicare

15 beneficiaries. Such information shall be submitted to

16 the Secretary not later than 45 days before the date

17 the information is first furnished to such bene18 ficiaries.

19 (4) CONSULTATION.—

20 (A) ADVISORY GROUPS.—In order to pro21 vide the information described in subsection

22 (a)(1), an MCC shall consult with an advisory

23 group. Each advisory group shall be comprised

24 of members who are representatives of each of

25 the persons described in subparagraph (B) who
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1 are located in or offering services in the Medi2 care market area.

3 (B) PERSONS DESCRIBED.—The persons

4 referred to in subparagraph (A) are private in5 surers, managed care plan providers, other

6 health care providers, and public and private

7 purchasers of health care benefits.

8 (C) PROHIBITION OF COMPENSATION.—

9 Members of an advisory group established

10 under this paragraph may not receive additional

11 pay, allowances, or benefits by reason of their

12 service on the advisory group.

13 (g) GROUP PURCHASING.—

14 (1) IN GENERAL.—For purposes of carrying out

15 the objectives described in subsection (a)(2), the

16 Secretary shall provide authority and establish meth17 ods for an MCC to negotiate with Medicare+Choice

18 plans and medigap plans to provide coalition mem19 bers with any or all of the following:

20 (A) Enhanced benefits.

21 (B) Lower premiums.

22 (C) Lower cost-sharing.

23 (2) MULTIYEAR CONTRACTS.—

24 (A) IN GENERAL.—Contracts entered into

25 with Medicare+Choice plans and medigap plans
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1 under the projects shall be for periods of not

2 less than one and not more than three years.

3 (B) PROVISIONS FOR OPEN ENROLLMENT

4 AND DISENROLLMENT.—Any contract entered

5 into under subparagraph (A) shall include pro6 visions for annual open enrollment and

7 disenrollment, and, in the case of disenrollment,

8 provisions for reenrollment in other

9 Medicare+Choice plans or a medigap plan

10 under which the Medicare beneficiary was pre11 viously enrolled.

12 (C) PAYMENT DIFFERENTIAL.—With re13 spect to different payment rates applicable to

14 Medicare+Choice plans under part C of title

15 XVIII of the Social Security Act for plans of16 fered in different regions in a Medicare market

17 area, an MCC may only enter into contracts

18 with such plans offered in regions within such

19 area in which such payments rates are the same

20 or similar.

21 (3) NO FINANCIAL UNDERWRITING.—An MCC

22 shall provide Medicare benefits coverage only

23 through Medicare+Choice plans and medigap plans,

24 as appropriate, and shall not assume insurance risk

25 with respect to such coverage.
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1 (4) MINIMUM COVERAGE.—An MCC may not

2 contract for health care coverage for members of the

3 coalition unless that coverage provides, at a min4 imum, the same items and services as what is avail5 able to Medicare beneficiaries enrolled in the fee-for6 service program under parts A and B of title XVIII

7 of the Social Security Act.

8 (5) CONTRACTS.—An MCC may enter into con9 tracts with other organizations, including pharmacy

10 benefit managers, to assist in carrying out the func11 tions described in subsection (a)(2).

12 (6) OVERSIGHT.—The Secretary may monitor

13 and approve contracts between an MCC and

14 Medicare+Choice plans and medigap plans to ensure

15 compliance with relevant consumer protections and

16 regulations applicable under title XVIII of the Social

17 Security Act.

18 (h) WAIVER AUTHORITY.—The Secretary may waive

19 such requirements of title XVIII of the Social Security Act

20 as may be necessary for the purposes of carrying out the

21 project.

22 (i) DEFINITIONS.—In this section:

23 (1) The term ‘‘Medicare+Choice plan’’ means a

24 Medicare+Choice plan offered by a

25 Medicare+Choice organization under part C of title
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1 XVIII of the Social Security Act (42 U.S.C. 1395w–

2 21 et seq.).

3 (2) The term ‘‘medigap plan’’ means a Medi4 care supplemental policy certified by the Secretary

5 under section 1882 of the Social Security Act (42

6 U.S.C. 1395ss).

7 (3) The term ‘‘Medicare beneficiary’’ means an

8 individual entitled to benefits under parts A, B, or

9 C of title XVIII of the Social Security Act.

10 (4) The terms ‘‘Medicare+Choice organization’’

11 and ‘‘Medicare+Choice plan’’ have the meaning

12 given those terms under subsections (a)(1) and

13 (b)(1), respectively, of section 1859 of the Social Se14 curity Act (42 U.S.C. 1395w–29).

15 (5) The term ‘‘Medicare market area’’ means

16 an area designated by the Secretary under sub17 section (c) in which an MCC shall carry out its func18 tions under the project.

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