I 

108TH CONGRESS 

2D SESSION H. R. 5400 

To provide for reimbursement of enrollees in the Medicare PPO Demonstration Project for expenses inappropriately incurred in being provided coverage through out-of-network providers. 

IN THE HOUSE OF REPRESENTATIVES 

NOVEMBER 19, 2004 

Mr. CARDIN introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and 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 provide for reimbursement of enrollees in the Medicare 

PPO Demonstration Project for expenses inappropriately 

incurred in being provided coverage through out-of-network providers. 

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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medicare PPO Fair5 ness Act of 2004’’. 
2 

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1 SEC. 2. REIMBURSEMENT OF ENROLLEES IN THE MEDI2 CARE PPO DEMONSTRATION PROJECT FOR 

3 EXPENSES FOR COVERED BENEFITS PRO4 VIDED THROUGH OUT-OF-NETWORK PRO5 VIDERS. 

6 (a) NOTICE.—The Secretary of Health and Human 

7 Services shall provide written notice to each individual who 

8 is, or has been, enrolled in the Medicare PPO Demonstra9 tion Project of the following: 

10 (1) The fact that enrollees under such project 

11 are, and have been, eligible for coverage of services 

12 whether the services were provided by in-network or 

13 out-of-network providers (pursuant to section 

14 1859(b)(2) of the Social Security Act (42 U.S.C. 

15 1395w–28(b)(2)). 

16 (2) There is a procedure, established under sub17 section (b), to provide for reimbursement for claims 

18 for services that should be (or have been) covered 

19 but were not covered because of their provision by 

20 an out-of-network provider in violation of the re21 quirement described in paragraph (1). 

22 (b) PROCEDURE FOR REIMBURSEMENT.—The Sec23 retary shall establish a procedure for reimbursement of en24 rollees under the Medicare PPO Demonstration Project 

25 for claims for services furnished before January 1, 2005, 

26 that should be (or have been) covered but were not covered 
3 

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1 because of their provision by an out-of-network provider 

2 in violation of the requirement described in subsection 

3 (a)(1). 

4 (c) ADJUSTMENT IN CAPITATION RATES.—The Sec5 retary shall provide for an adjustment in the capitation 

6 rates for plans under the Medicare PPO Demonstration 

7 Project for months in 2005 so as to reduce payment under 

8 such rates, in the aggregate, by the aggregate amount of 

9 payments the Secretary estimates will be paid under sub10 section (b). 

11 (d) DEFINITIONS.—For purposes of this section: 

12 (1) MEDICARE PPO DEMONSTRATION PROJECT

13 DEFINED.—The term ‘‘Medicare PPO Demonstra14 tion Project’’ means the Medicare Preferred Pro15 vider Organization (PPO) Demonstration conducted 

16 by the Secretary under the authority of section 

17 402(a) of the Social Security Amendments of 1967 

18 (Public Law 90–248; 42 U.S.C. 1395b–1(a)). 

19 (2) SECRETARY.—The term ‘‘Secretary’’ means 

20 the Secretary of Health and Human Services. 

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