217 
(1) by inserting ‘‘(before 2009)’’ after ‘‘for subse-
quent years’’; and 
(2) by inserting before the period at the end the 
following: ‘‘and for each year beginning with 2009’’. 
(e) REPEAL OF PPO STABILIZATION FUND.—Section 
1858 of the Social Security Act (42 U.S.C. 1395) is amend-
ed— 
(1) by striking subsection (e); and 
(2) in subsection (f)(1), by striking ‘‘subject to 
subsection (e),’’. 
Subtitle B—Beneficiary Protections 
SEC. 411. NAIC DEVELOPMENT OF MARKETING, ADVER-
TISING, AND RELATED PROTECTIONS. 
(a) IN GENERAL.—Section 1852 of the Social Security 
Act (42 U.S.C. 1395w–22) is amended by adding at the 
end the following new subsection: 
‘‘(m) APPLICATION OF MODEL MARKETING AND EN-
ROLLMENT STANDARDS.— 
‘‘(1) IN GENERAL.—The National Association of 
Insurance Commissioners (in this subsection referred 
to as the ‘NAIC’) is requested to develop, and to sub-
mit to the Secretary of Health and Human Services 
not later than 12 months after the date of the enact-
ment of this Act, model regulations (in this section re-
ferred to as ‘model regulations’) regarding Medicare 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00217
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
218 
plan marketing, enrollment, broker and agent train-
ing and certification, agent and broker commissions, 
and market conduct by plans, agents and brokers for 
implementation (under paragraph (7)) under this 
part and part D, including for enforcement by States 
under section 1856(b)(3). 
‘‘(2) MARKETING GUIDELINES.— 
‘‘(A) IN GENERAL.—The model regulations 
shall address the sales and advertising techniques 
used by Medicare private plans, agents and bro-
kers in selling plans, including defining and 
prohibiting cold calls, unsolicited door-to-door 
sales, cross-selling, and co-branding. 
‘‘(B) 
SPECIAL
CONSIDERATIONS.—The 
model regulations shall specifically address the 
marketing— 
‘‘(i) of plans to full benefit dual-eligible 
individuals and qualified medicare bene-
ficiaries; 
‘‘(ii) of plans to populations with lim-
ited English proficiency; 
‘‘(iii) of plans to beneficiaries in senior 
living facilities; and 
‘‘(iv) of plans at educational events. 
‘‘(3) ENROLLMENT GUIDELINES.— 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00218
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
219 
‘‘(A) IN GENERAL.—The model regulations 
shall address the disclosures Medicare private 
plans, agents, and brokers must make when en-
rolling beneficiaries, and a process— 
‘‘(i) for affirmative beneficiary sign off 
before enrollment in a plan; and 
‘‘(ii) in the case of Medicare Part C 
plans, for plans to conduct a beneficiary 
call-back to confirm beneficiary sign off and 
enrollment. 
‘‘(B) 
SPECIFIC
CONSIDERATIONS.—The 
model regulations shall specially address bene-
ficiary understanding of the Medicare plan 
through required disclosure (or beneficiary 
verification) of each of the following: 
‘‘(i) The type of Medicare private plan 
involved. 
‘‘(ii) Attributes of the plan, including 
premiums, cost sharing, formularies (if ap-
plicable), benefits, and provider access limi-
tations in the plan. 
‘‘(iii) Comparative quality of the plan. 
‘‘(iv) The fact that plan attributes may 
change annually. 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00219
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
220 
‘‘(4) APPOINTMENT, CERTIFICATION AND TRAIN-
ING OF AGENTS AND BROKERS.—The model regula-
tions shall establish procedures and requirements for 
appointment, certification (and periodic recertifi-
cation), and training of agents and brokers that mar-
ket or sell Medicare private plans consistent with ex-
isting State appointment and certification procedures 
and with this paragraph. 
‘‘(5) AGENT AND BROKER COMMISSIONS.— 
‘‘(A) IN GENERAL.—The model regulations 
shall establish standards for fair and appro-
priate commissions for agents and brokers con-
sistent with this paragraph. 
‘‘(B) LIMITATION
ON
TYPES
OF
COMMIS-
SION.—The model regulations shall specifically 
prohibit the following: 
‘‘(i) Differential commissions— 
‘‘(I) for Medicare Part C plans 
based on the type of Medicare private 
plan; or 
‘‘(II) 
prescription 
drug 
plans 
under part D based on the type of pre-
scription drug plan. 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00220
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
221 
‘‘(ii) Commissions in the first year 
that are more than 200 percent of subse-
quent year commissions. 
‘‘(iii) The payment of extra bonuses or 
incentives (such as trips, gifts, and other 
non-commission cash payments). 
‘‘(C) AGENT
DISCLOSURE.—In developing 
the model regulations, the NAIC shall consider 
requiring agents and brokers to disclose commis-
sions to a beneficiary upon request of the bene-
ficiary before enrollment. 
‘‘(D) PREVENTION OF FRAUD.—The model 
regulations shall consider the opportunity for 
fraud and abuse and beneficiary steering in set-
ting standards under this paragraph and shall 
provide for the ability of State commissioners to 
investigate commission structures. 
‘‘(6) MARKET CONDUCT.— 
‘‘(A) IN GENERAL.—The model regulations 
shall establish standards for the market conduct 
of organizations offering Medicare private plans, 
and of agents and brokers selling such plans, and 
for State review of plan market conduct. 
‘‘(B) MATTERS
TO
BE
INCLUDED.—Such 
standards shall include standards for— 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00221
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
222 
‘‘(i) timely payment of claims; 
‘‘(ii) beneficiary complaint reporting 
and disclosure; and 
‘‘(iii) State reporting of market con-
duct violations and sanctions. 
‘‘(7) IMPLEMENTATION.— 
‘‘(A) PUBLICATION OF NAIC MODEL REGU-
LATIONS.—If the model regulations are sub-
mitted on a timely basis under paragraph (1)— 
‘‘(i) the Secretary shall publish them 
in the Federal Register upon receipt and re-
quest public comment on the issue of wheth-
er such regulations are consistent with the 
requirements established in this subsection 
for such regulations; 
‘‘(ii) not later than 6 months after the 
date of such publication, the Secretary shall 
determine whether such regulations are so 
consistent with such requirements and shall 
publish notice of such determination in the 
Federal Register; 
‘‘(iii) if the Secretary makes the deter-
mination under clause (ii) that such regula-
tions are consistent with such requirements, 
in the notice published under clause (ii) the 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00222
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
223 
Secretary shall publish notice of adoption of 
such model regulations as constituting the 
marketing and enrollment standards adopt-
ed under this subsection to be applied under 
this title; and 
‘‘(iv) if the Secretary makes the deter-
mination under such clause that such regu-
lations are not consistent with such require-
ments, the procedures of clauses (ii) and 
(iii) of subparagraph (B) shall apply (in 
relation to the notice published under clause 
(ii)), in the same manner as such clauses 
would apply in the case of publication of a 
notice under subparagraph (B)(i). 
‘‘(B) NO
MODEL
REGULATIONS.—If the 
model regulations are not submitted on a timely 
basis under paragraph (1)— 
‘‘(i) the Secretary shall publish notice 
of such fact in the Federal Register; 
‘‘(ii) not later than 6 months after the 
date of publication of such notice, the Sec-
retary shall propose regulations that pro-
vide for marketing and enrollment stand-
ards that incorporate the requirements of 
this subsection for the model regulations 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00223
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
224 
and request public comments on such pro-
posed regulations; and 
‘‘(iii) not later than 6 months after the 
date of publication of such proposed regula-
tions, the Secretary shall publish final regu-
lations that shall constitute the marketing 
and enrollment standards adopted under 
this subsection to be applied under this title. 
‘‘(C) REFERENCES TO MARKETING AND EN-
ROLLMENT
STANDARDS.—In this title, a ref-
erence to marketing and enrollment standards 
adopted under this subsection is deemed a ref-
erence to the regulations constituting such stand-
ards adopted under subparagraph (A) or (B), as 
the case may be. 
‘‘(D) EFFECTIVE DATE OF STANDARDS.—In 
order to provide for the orderly and timely im-
plementation of marketing and enrollment stand-
ards adopted under this subsection, the Sec-
retary, in consultation with the NAIC, shall 
specify (by program instruction or otherwise) ef-
fective dates with respect to all components of 
such standards consistent with the following: 
‘‘(i) In the case of components that re-
late predominantly to operations in relation 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00224
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
225 
to Medicare private plans, the effective date 
shall be for plan years beginning on or after 
such date (not later than 1 year after the 
date of promulgation of the standards) as 
the Secretary specifies. 
‘‘(ii) In the case of other components, 
the effective date shall be such date, not 
later than 1 year after the date of promul-
gation of the standards, as the Secretary 
specifies. 
‘‘(E) 
CONSULTATION.—In 
promulgating 
marketing and enrollment standards under this 
paragraph, the NAIC or Secretary shall consult 
with a working group composed of representa-
tives of issuers of Medicare private plans, con-
sumer groups, medicare beneficiaries, State 
Health Insurance Assistance Programs, and 
other qualified individuals. Such representatives 
shall be selected in a manner so as to assure bal-
anced 
representation 
among 
the 
interested 
groups. 
‘‘(8) ENFORCEMENT.— 
‘‘(A) IN GENERAL.—Any Medicare private 
plan that violates marketing and enrollment 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00225
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
226 
standards is subject to sanctions under section 
1857(g). 
‘‘(B) STATE
RESPONSIBILITIES.—Nothing 
in this subsection or section 1857(g) shall pro-
hibit States from imposing sanctions against 
Medicare private plans, agents, or brokers for 
violations of the marketing and enrollment 
standards adopted under section 1852(m). States 
shall have the sole authority to regulate agents 
and brokers. 
‘‘(9) MEDICARE
PRIVATE
PLAN
DEFINED.—In 
this subsection, the term ‘Medicare private plan’ 
means a Medicare Part C plan and a prescription 
drug plan under part D.’’. 
(b) EXPANSION OF EXCEPTION TO PREEMPTION OF 
STATE ROLE.— 
(1) IN GENERAL.—Section 1856(b)(3) of the So-
cial Security Act (42 U.S.C. 1395w–26(b)(3)) is 
amended by striking ‘‘(other than State licensing laws 
or State laws relating to plan solvency)’’ and insert-
ing ‘‘(other than State laws relating to licensing or 
plan solvency and State laws or regulations adopting 
the marketing and enrollment standards adopted 
under section 1852(m))’’. 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00226
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
227 
(2) EFFECTIVE DATE.—The amendment made by 
paragraph (1) shall apply to plans offered on or after 
July 1, 2008. 
(c) APPLICATION TO PRESCRIPTION DRUG PLANS.— 
(1) IN GENERAL.—Section 1860D–1 of such Act 
is amended by adding at the end the following new 
subsection: 
‘‘(d) APPLICATION OF MARKETING AND ENROLLMENT 
STANDARDS.—The marketing and enrollment standards 
adopted under section 1852(m) shall apply to prescription 
drug plans (and sponsors of such plans) in the same man-
ner as they apply to Medicare Part C plans and organiza-
tions offering such plans.’’. 
(2) REFERENCE
TO
CURRENT
LAW
PROVI-
SIONS.—The amendment made by subsection (a) and 
(b) apply, pursuant to section 1860D–1(b)(1)(B)(ii) 
of the Social Security Act (42 U.S.C. 1395w– 
101(b)(1)(B)(ii)), to prescription drug plans under 
part D of title XVIII of such Act. 
(d) CONTRACT REQUIREMENT TO MEET MARKETING 
AND ADVERTISING STANDARDS.— 
(1) IN GENERAL.—Section 1857(d) of the Social 
Security Act (42 U.S.C. 1395w–27(d)), as amended 
by subsection (b)(1), is further amended by adding at 
the end the following new paragraph: 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00227
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
228 
‘‘(7) MARKETING
AND
ADVERTISING
STAND-
ARDS.—The contract shall require the organization to 
meet all standards adopted under section 1852(m) 
(including those enforced by the State involved pursu-
ant to section 1856(b)(3)) relating to marketing and 
advertising conduct.’’. 
(2) EFFECTIVE DATE.—The amendment made by 
paragraph (1) shall apply to contracts for plan years 
beginning on or after January 1, 2011. 
(e) APPLICATION OF SANCTIONS.— 
(1) APPLICATION TO VIOLATION OF MARKETING 
AND
ENROLLMENT
STANDARDS.—Section 1857(g)(1) 
of such Act (42 U.S.C. 1395w–27(g)(1)), as amended 
by the preceding provisions of this Act, is further 
amended— 
(A) by striking ‘‘and’’ at the end of sub-
paragraph (G); 
(B) by adding ‘‘and’’ at the end of subpara-
graph (H); and 
(C) by inserting after subparagraph (H) the 
following new subparagraph: 
‘‘(I) violates marketing and enrollment 
standards adopted under section 1852(m);’’. 
(2) ENHANCED CIVIL MONEY SANCTIONS.—Such 
section is further amended— 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00228
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
229 
(A) in paragraph (2)(A), by striking 
‘‘$25,000’’, ‘‘$100,000’’, and ‘‘$15,000’’ and in-
serting ‘‘$50,000’’, ‘‘$200,000’’, and ‘‘$30,000’’, 
respectively; and 
(B) in subparagraphs (A), (B), and (D) of 
paragraph 
(3), 
by 
striking 
‘‘$25,000’’, 
‘‘$10,000’’, and ‘‘$100,000’’, respectively, and in-
serting ‘‘$50,000’’, ‘‘$20,000’’, and ‘‘$200,000’’, 
respectively. 
(3) EFFECTIVE DATE.—The amendments made 
by paragraph (2) shall apply to violations occurring 
on or after the date of the enactment of this Act. 
(f) DISCLOSURE OF MARKET AND ADVERTISING CON-
TRACT VIOLATIONS
AND IMPOSED SANCTIONS.—Section 
1857 of such Act is amended by adding at the end the fol-
lowing new subsection 
‘‘(j) DISCLOSURE OF MARKET AND ADVERTISING CON-
TRACT VIOLATIONS AND IMPOSED SANCTIONS.—For years 
beginning with 2009, the Secretary shall post on its public 
website for the Medicare program an annual report that— 
‘‘(1) lists each MA organization for which the 
Secretary made during the year a determination 
under subsection (c)(2) the basis of which is described 
in paragraph (1)(E); and 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00229
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
230 
‘‘(2) that describes any applicable sanctions 
under subsection (g) applied to such organization 
pursuant to such determination.’’. 
(g) STANDARD DEFINITIONS OF BENEFITS AND FOR-
MATS
FOR
USE
IN
MARKETING
MATERIALS.—Section 
1851(h) of such Act (42 U.S.C. 1395w–21(h)) is amended 
by adding at the end the following new paragraph: 
‘‘(6) STANDARD DEFINITIONS OF BENEFITS AND 
FORMATS FOR USE IN MARKETING MATERIALS.— 
‘‘(A) IN GENERAL.—Not later than January 
1, 2010, the Secretary, in consultation with the 
National Association of Insurance Commis-
sioners and a working group of the type de-
scribed in section 1852(m)(7)(E), shall develop 
standard descriptions and definitions for benefits 
under this title for use in marketing material 
distributed by Medicare Part C organizations 
and formats for including such descriptions in 
such marketing material. 
‘‘(B) REQUIRED USE OF STANDARD DEFINI-
TIONS.—For plan years beginning on or after 
January 1, 2011, the Secretary shall disapprove 
the distribution of marketing material under 
paragraph (1)(B) if such marketing material 
does not use, without modification, the applica-
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00230
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
231 
ble descriptions and formats specified under sub-
paragraph (A).’’. 
(h) SUPPORT FOR STATE HEALTH INSURANCE ASSIST-
ANCE PROGRAMS (SHIPS).—Section 1857(e)(2) of the So-
cial Security Act (42 U.S.C. 1395w–27(e)(2)) is amended— 
(1) in subparagraph (B), by adding at the end 
the following: ‘‘Of the amounts so collected, no less 
than $55,000,000 for fiscal year 2009, $65,000,000 for 
fiscal year 2010, $75,000,000 for fiscal year 2011, 
and $85,000,000 for fiscal year 2012 and each suc-
ceeding fiscal year shall be used to support Medicare 
Part C and Part D counseling and assistance pro-
vided by State Health Insurance Assistance Pro-
grams.’’; 
(2) in subparagraph (C)— 
(A) 
by 
striking 
‘‘and’’ 
after 
‘‘$100,000,000,’’; 
(B) by striking ‘‘an amount equal to 
$200,000,000’’ and inserting ‘‘and ending with 
fiscal 
year 
2008 
an 
amount 
equal 
to 
$200,000,000, for fiscal year 2009 an amount 
equal to $255,000,000, for fiscal year 2010 an 
amount equal to $265,000,000, for fiscal year 
2011 an amount equal to $275,000,000, and for 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00231
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
232 
fiscal year 2012 and each succeeding fiscal year 
an amount equal to $285,000,000’’; and 
(C) by adding at the end the following: 
‘‘The amounts in excess of $200,000,000 in any 
fiscal year shall be used to support State Health 
Insurance Assistance Programs under subpara-
graph (B) and the remaining amount used to 
support activities related to enrollment and dis-
semination of information.’’; and 
(3) in subparagraph (D)(ii)— 
(A) by striking ‘‘and’’ at the end of sub-
clause (IV); 
(B) in subclause (V), by striking the period 
at the end and inserting ‘‘before fiscal year 2009; 
and’’; and 
(C) by adding at the end the following new 
subclause: 
‘‘(VI) for fiscal year 2009 and each 
succeeding fiscal year the applicable portion 
(as so defined) of the amount specified in 
subparagraph (C) for that fiscal year.’’. 
SEC. 412. LIMITATION ON OUT-OF-POCKET COSTS FOR INDI-
VIDUAL HEALTH SERVICES. 
(a) IN GENERAL.—Section 1852(a)(1) of the Social Se-
curity Act (42 U.S.C. 1395w–22(a)(1)) is amended— 
VerDate Aug 31 2005 
04:08 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00232
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
233 
(1) in subparagraph (A), by inserting before the 
period at the end the following: ‘‘with cost-sharing 
that is no greater (and may be less) than the cost- 
sharing that would otherwise be imposed under such 
program option’’; 
(2) in subparagraph (B)(i), by striking ‘‘or an 
actuarially equivalent level of cost-sharing as deter-
mined in this part’’; and 
(3) by amending clause (ii) of subparagraph (B) 
to read as follows: 
‘‘(ii) PERMITTING USE OF FLAT COPAY-
MENT
OR
PER
DIEM
RATE.—Nothing in 
clause (i) shall be construed as prohibiting 
a Medicare part C plan from using a flat 
copayment or per diem rate, in lieu of the 
cost-sharing that would be imposed under 
part A or B, so long as the amount of the 
cost-sharing imposed does not exceed the 
amount of the cost-sharing that would be 
imposed under the respective part if the in-
dividual were not enrolled in a plan under 
this part.’’. 
(b) LIMITATION FOR DUAL ELIGIBLES AND QUALIFIED 
MEDICARE BENEFICIARIES.—Section 1852(a) of such Act 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00233
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
234 
is amended by adding at the end the following new para-
graph: 
‘‘(7) LIMITATION ON COST-SHARING FOR DUAL 
ELIGIBLES
AND
QUALIFIED
MEDICARE
BENE-
FICIARIES.—In the case of a individual who is a full- 
benefit dual eligible individual (as defined in section 
1935(c)(6)) or a qualified medicare beneficiary (as 
defined in section 1905(p)(1)) who is enrolled in a 
Medicare Part C plan, the plan may not impose cost- 
sharing that exceeds the amount of cost-sharing that 
would be permitted with respect to the individual 
under this title and title XIX if the individual were 
not enrolled with such plan.’’. 
(c) EFFECTIVE DATES.— 
(1) The amendments made by subsection (a) 
shall apply to plan years beginning on or after Janu-
ary 1, 2009. 
(2) The amendments made by subsection (b) 
shall apply to plan years beginning on or after Janu-
ary 1, 2008. 
SEC. 413. MA PLAN ENROLLMENT MODIFICATIONS. 
(a) IMPROVED PLAN ENROLLMENT, DISENROLLMENT, 
AND CHANGE OF ENROLLMENT.— 
(1) CONTINUOUS OPEN ENROLLMENT FOR FULL- 
BENEFIT DUAL ELIGIBLE INDIVIDUALS AND QUALI-
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00234
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
235 
FIED
MEDICARE
BENEFICIARIES
(QMB).—Section 
1851(e)(2)(D) of the Social Security Act (42 U.S.C. 
1395w–21(e)(2)(D)) is amended— 
(A) in the heading, by inserting ‘‘, FULL- 
BENEFIT
DUAL
ELIGIBLE
INDIVIDUALS, 
AND 
QUALIFIED MEDICARE BENEFICIARIES’’ after ‘‘IN-
STITUTIONALIZED INDIVIDUALS’’; and 
(B) in the matter before clause (i), by in-
serting ‘‘, a full-benefit dual eligible individual 
(as defined in section 1935(c)(6)), or a qualified 
medicare beneficiary (as defined in section 
1905(p)(1))’’ after ‘‘institutionalized (as defined 
by the Secretary)’’; and 
(C) in clause (i), by inserting ‘‘or disenroll’’ 
after ‘‘enroll’’. 
(2) SPECIAL
ELECTION
PERIODS
FOR
ADDI-
TIONAL
CATEGORIES
OF
INDIVIDUALS.—Section 
1851(e)(4) of such Act (42 U.S.C. 1395w(e)(4)) is 
amended— 
(A) in subparagraph (C), by striking at the 
end ‘‘or’’; 
(B) in subparagraph (D), by inserting ‘‘, 
taking into account the health or well-being of 
the individual’’ before the period and redesig-
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00235
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
236 
nating such subparagraph as subparagraph (F); 
and 
(C) by inserting after subparagraph (C) the 
following new subparagraphs: 
‘‘(D) the individual is described in section 
1902(a)(10)(E)(iii) (relating to specified low-in-
come medicare beneficiaries); 
‘‘(E) the individual is enrolled in an MA 
plan and enrollment in the plan is suspended 
under paragraph (2)(B) or (3)(C) of section 
1857(g) because of a failure of the plan to meet 
applicable requirements; or’’. 
(3) EFFECTIVE DATE.—The amendments made 
by this subsection shall take effect on the date of the 
enactment of this Act. 
(b) ACCESS TO MEDIGAP COVERAGE FOR INDIVIDUALS 
WHO LEAVE MA PLANS.— 
(1) IN GENERAL.—Section 1882(s)(3) of the So-
cial Security Act (42 U.S.C. 1395ss(s)(3)) is amend-
ed— 
(A) in each of clauses (v)(III) and (vi) of 
subparagraph (B), by striking ‘‘12 months’’ and 
inserting ‘‘24 months’’; and 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00236
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
237 
(B) in each of subclauses (I) and (II) of 
subparagraph (F)(i), by striking ‘‘12 months’’ 
and inserting ‘‘24 months’’. 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall apply to terminations of en-
rollments in MA plans occurring on or after the date 
of the enactment of this Act. 
(c) IMPROVED ENROLLMENT POLICIES.— 
(1) NO AUTO-ENROLLMENT OF MEDICAID BENE-
FICIARIES.— 
(A) IN GENERAL.—Section 1851(e) of such 
Act (42 U.S.C. 1395w–21(e)) is amended by add-
ing at the end the following new paragraph: 
‘‘(7) NO AUTO-ENROLLMENT OF MEDICAID BENE-
FICIARIES.—In no case may the Secretary provide for 
the enrollment in a MA plan of a Medicare Advan-
tage eligible individual who is eligible to receive med-
ical assistance under title XIX as a full-benefit dual 
eligible individual or a qualified medicare bene-
ficiary, without the affirmative application of such 
individual (or authorized representative of the indi-
vidual) to be enrolled in such plan.’’. 
(B) NO
APPLICATION
TO
PRESCRIPTION 
DRUG PLANS.—Section 1860D–1(b)(1)(B)(iii) of 
VerDate Aug 31 2005 
04:08 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00237
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
238 
such Act (42 U.S.C. 1395w–101(b)(1)(B)(iii)) is 
amended— 
(i) by striking ‘‘paragraph (2) and’’ 
and by inserting ‘‘paragraph (2),’’; and 
(ii) by inserting ‘‘, and paragraph 
(7),’’ after ‘‘paragraph (4)’’. 
(C) EFFECTIVE
DATE.—The amendments 
made by this paragraph shall apply to enroll-
ments that are effective on or after the date of the 
enactment of this Act. 
SEC. 414. INFORMATION FOR BENEFICIARIES ON MA PLAN 
ADMINISTRATIVE COSTS. 
(a) DISCLOSURE
OF MEDICAL LOSS RATIOS
AND 
OTHER EXPENSE DATA.—Section 1851 of the Social Secu-
rity Act (42 U.S.C. 1395w–21) is amended by adding at 
the end the following new subsection: 
‘‘(j) PUBLICATION OF MEDICAL LOSS RATIOS AND 
OTHER COST-RELATED INFORMATION.— 
‘‘(1) IN GENERAL.—The Secretary shall publish, 
not later than October 1 of each year (beginning with 
2009), for each Medicare Part C plan contract, the 
following: 
‘‘(A) The medical loss ratio of the plan in 
the previous year. 
VerDate Aug 31 2005 
04:08 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00238
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
239 
‘‘(B) The per enrollee payment under this 
part to the plan, as adjusted to reflect a risk 
score (based on factors described in section 
1853(a)(1)(C)(i)) of 1.0. 
‘‘(C) The average risk score (as so based). 
‘‘(2) SUBMISSION OF DATA.— 
‘‘(A) IN GENERAL.—Each Medicare Part C 
organization shall submit to the Secretary, in a 
form and manner specified by the Secretary, 
data necessary for the Secretary to publish the 
information described in paragraph (1) on a 
timely basis, including the information described 
in paragraph (3). 
‘‘(B) DATA FOR 2008 AND 2009.—The data 
submitted under subparagraph (A) for 2008 and 
for 2009 shall be consistent in content with the 
data reported as part of the Medicare Part C 
plan bid in June 2007 for 2008. 
‘‘(C) MEDICAL
LOSS
RATIO
DATA.—The 
data to be submitted under subparagraph (A) re-
lating to medical loss ratio for a year— 
‘‘(i) shall be submitted not later than 
June 1 of the following year; and 
‘‘(ii) beginning with 2010, shall be 
submitted based on the standardized ele-
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00239
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
240 
ments and definitions developed under 
paragraph (4). 
‘‘(D) 
AUDITED
DATA.—Data 
submitted 
under this paragraph shall be data that has been 
audited by an independent third party auditor. 
‘‘(3) MLR INFORMATION.—The information de-
scribed in this paragraph with respect to a Medicare 
Part C plan for a year is as follows: 
‘‘(A) The costs for the plan in the previous 
year for each of the following: 
‘‘(i) Total medical expenses, separately 
indicated for benefits for the original medi-
care fee-for-service program option and for 
supplemental benefits. 
‘‘(ii) Non-medical expenses, shown sep-
arately for each of the following categories 
of expenses: 
‘‘(I) Marketing and sales. 
‘‘(II) Direct administration. 
‘‘(III) Indirect administration. 
‘‘(IV) Net cost of private reinsur-
ance. 
‘‘(B) Gain or loss margin. 
‘‘(C) Total revenue requirement, computed 
as the total of medical and nonmedical expenses 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00240
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
241 
and gain or loss margin, multiplied by the gain 
or loss margin. 
‘‘(D) Percent of revenue ratio, computed as 
the total revenue requirement expressed as a per-
centage of revenue. 
‘‘(4) DEVELOPMENT OF DATA REPORTING STAND-
ARDS.— 
‘‘(A) IN GENERAL.—The Secretary shall de-
velop and implement standardized data elements 
and definitions for reporting under this sub-
section, for contract years beginning with 2010, 
of data necessary for the calculation of the med-
ical loss ratio for Medicare Part C plans. Not 
later than December 31, 2008, the Secretary 
shall publish a report describing the elements 
and definitions so developed. 
‘‘(B) CONSULTATION.—The Secretary shall 
consult with representatives of Medicare Part C 
organizations, experts on health plan accounting 
systems, and representatives of the National As-
sociation of Insurance Commissioners, in the de-
velopment of such data elements and definitions 
‘‘(5) MEDICAL LOSS RATIO DEFINED.—For pur-
poses of this part, the term ‘medical loss ratio’ means, 
with respect to an MA plan for a year, the ratio of— 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00241
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
242 
‘‘(A) the aggregate benefits (excluding non-
medical 
expenses 
described 
in 
paragraph 
(3)(A)(ii)) paid under the plan for the year, to 
‘‘(B) the aggregate amount of premiums 
(including basic and supplemental beneficiary 
premiums) and payments made under sections 
1853 and 1860D–15) collected for the plan and 
year. 
Such ratio shall be computed without regard to 
whether the benefits or premiums are for required or 
supplemental benefits under the plan.’’. 
(b) AUDIT OF ADMINISTRATIVE COSTS AND COMPLI-
ANCE WITH THE FEDERAL ACQUISITION REGULATION.— 
(1) IN GENERAL.—Section 1857(d)(2)(B) of such 
Act (42 U.S.C. 1395w–27(d)(2)(B)) is amended— 
(A) by striking ‘‘or (ii)’’ and inserting 
‘‘(ii)’’; and 
(B) by inserting before the period at the end 
the following: ‘‘, or (iii) to compliance with the 
requirements of subsection (e)(4) and the extent 
to which administrative costs comply with the 
applicable requirements for such costs under the 
Federal Acquisition Regulation’’. 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00242
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
243 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply for contract years be-
ginning after the date of the enactment of this Act. 
(c) MINIMUM MEDICAL LOSS RATIO.—Section 1857(e) 
of the Social Security Act (42 U.S.C. 1395w–27(e)) is 
amended by adding at the end the following new paragraph: 
‘‘(4) REQUIREMENT
FOR
MINIMUM
MEDICAL 
LOSS RATIO.—If the Secretary determines for a con-
tract year (beginning with 2010) that an MA plan 
has failed to have a medical loss ratio (as defined in 
section 1851(j)(4)) of at least .85— 
‘‘(A) for that contract year, the Secretary 
shall reduce the blended benchmark amount 
under subsection (l) for the second succeeding 
contract year by the numer of percentage points 
by which such loss ratio was less than 85 per-
cent; 
‘‘(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.’’. 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00243
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
244 
(d) INFORMATION ON MEDICARE PART C PLAN EN-
ROLLMENT AND SERVICES.—Section 1851 of such Act, as 
amended by subsection (a), is further amended by adding 
at the end the following new subsection: 
‘‘(k) PUBLICATION OF ENROLLMENT AND OTHER IN-
FORMATION.— 
‘‘(1) MONTHLY PUBLICATION OF PLAN-SPECIFIC 
ENROLLMENT DATA.—The Secretary shall publish (on 
the public website of the Centers for Medicare & Med-
icaid Services or otherwise) not later than 30 days 
after the end of each month (beginning with January 
2008) on the actual enrollment in each Medicare Part 
C plan by contract and by county. 
‘‘(2) AVAILABILITY OF OTHER INFORMATION.— 
The Secretary shall make publicly available data and 
other information in a format that may be readily 
used for analysis of the Medicare Part C program 
under this part and will contribute to the under-
standing of the organization and operation of such 
program.’’. 
(e) MEDPAC REPORT ON VARYING MINIMUM MEDICAL 
LOSS RATIOS.— 
(1) STUDY.—The Medicare Payment Advisory 
Commission shall conduct a study of the need and 
feasibility ofproviding for different minimum medical 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00244
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
245 
loss ratios for different types of Medicare Part C 
plans, including coordinated care plans, group model 
plans, coordinated care independent practice associa-
tion plans, preferred provider organization plans, 
and private fee-for-services plans. 
(2) REPORT.—Not later than 1 year after the 
date of the enactment of this Act, submit to Congress 
a report on the study conducted under paragraph (1). 
Subtitle C—Quality and Other 
Provisions 
SEC. 421. REQUIRING ALL MA PLANS TO MEET EQUAL 
STANDARDS. 
(a) COLLECTION AND REPORTING OF INFORMATION.— 
(1) IN GENERAL.—Section 1852(e)(1) of the So-
cial Security Act (42 U.S.C. 1395w–112(e)(1)) is 
amended by striking ‘‘(other than an MA private fee- 
for-service plan or an MSA plan)’’. 
(2) REPORTING FOR PRIVATE FEE-FOR-SERVICES 
AND MSA PLANS.—Section 1852(e)(3) of such Act is 
amended by adding at the end the following new sub-
paragraph: 
‘‘(C) DATA COLLECTION REQUIREMENTS BY 
PRIVATE
FEE-FOR-SERVICE
PLANS
AND
MSA 
PLANS.— 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00245
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
246 
‘‘(i) USING MEASURES FOR PPOS FOR 
CONTRACT
YEAR
2009.—For contract year 
2009, the Medicare Part C organization of-
fering a private fee-for-service plan or an 
MSA plan shall submit to the Secretary for 
such plan the same information on the same 
performance measures for which such infor-
mation is required to be submitted for 
Medicare Part C plans that are preferred 
provider organization plans for that year. 
‘‘(ii) APPLICATION OF SAME MEASURES 
AS COORDINATED CARE PLANS BEGINNING 
IN CONTRACT YEAR 2010.—For a contract 
year beginning with 2010, a Medicare Part 
C organization offering a private fee-for- 
service plan or an MSA plan shall submit 
to the Secretary for such plan the same in-
formation on the same performance meas-
ures for which such information is required 
to be submitted for such contract year Medi-
care Part C plans described in section 
1851(a)(2)(A)(i) for contract year such con-
tract year.’’. 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00246
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
247 
(3) EFFECTIVE DATE.—The amendment made by 
paragraph (1) shall apply to contract years beginning 
on or after January 1, 2009. 
(b) EMPLOYER PLANS.— 
(1) IN GENERAL.—The first sentence of para-
graph (2) of section 1857(i) of such Act (42 U.S.C. 
1395w–27(i)) is amended by inserting before the pe-
riod at the end the following: ‘‘, but only if 90 percent 
of the Medicare part C eligible individuals enrolled 
under such plan reside in a county in which the 
Medicare Part C organization offers a Medicare Part 
C local plan’’. 
(2) LIMITATION ON APPLICATION OF WAIVER AU-
THORITY.—Paragraphs (1) and (2) of such section 
are each amended by inserting ‘‘that were in effect be-
fore the date of the enactment of the Children’s Health 
and Medicare Protection Act of 2007’’ after ‘‘waive or 
modify requirements’’. 
(3) EFFECTIVE DATES.—The amendment made 
by paragraph (1) shall apply for plan years begin-
ning on or after January 1, 2009, and the amend-
ments made by paragraph (2) shall take effect on the 
date of the enactment of this Act. 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00247
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
248 
SEC. 422. DEVELOPMENT OF NEW QUALITY REPORTING 
MEASURES ON RACIAL DISPARITIES. 
(a) NEW QUALITY REPORTING MEASURES.— 
(1) IN GENERAL.—Section 1852(e)(3) of the So-
cial Security Act (42 U.S.C. 1395w–22(e)(3)), as 
amended by section 421(a)(2), is amended— 
(A) in subparagraph (B)— 
(i) in clause (i), by striking ‘‘The Sec-
retary’’ and inserting ‘‘Subject to subpara-
graph (D), the Secretary’’; and 
(ii) in clause (ii), by striking ‘‘sub-
clause (iii)’’ and inserting ‘‘clause (iii) and 
subparagraph (C)’’ ; and 
(B) by adding at the end the following new 
subparagraph: 
‘‘(D) 
ADDITIONAL
QUALITY
REPORTING 
MEASURES.— 
‘‘(i) IN GENERAL.—The Secretary shall 
develop by October 1, 2009, quality meas-
ures for Medicare Part C plans that meas-
ure disparities in the amount and quality 
of health services provided to racial and eth-
nic minorities. 
‘‘(ii) DATA TO MEASURE RACIAL AND 
ETHNIC DISPARITIES IN THE AMOUNT AND 
QUALITY OF CARE PROVIDED TO ENROLL-
VerDate Aug 31 2005 
04:08 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00248
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
249 
EES.—The Secretary shall provide for Medi-
care Part C organizations to submit data 
under this paragraph, including data simi-
lar to those submitted for other quality 
measures, that permits analysis of dispari-
ties among racial and ethnic minorities in 
health services, quality of care, and health 
status among Medicare Part C plan enroll-
ees for use in submitting the reports under 
paragraph (5).’’. 
(2) EFFECTIVE DATE.—The amendments made 
by this subsection shall apply to reporting of quality 
measures for plan years beginning on or after Janu-
ary 1, 2010. 
(b) BIENNIAL REPORT ON RACIAL AND ETHNIC MI-
NORITIES.—Section 1852(e) of such Act (42 U.S.C. 1395w– 
22(e)) is amended by adding at the end the following new 
paragraph: 
‘‘(5) REPORT TO CONGRESS.— 
‘‘(A) IN GENERAL.—Not later than 2 years 
after the date of the enactment of this paragraph, 
and biennially thereafter, the Secretary shall 
submit to Congress a report regarding how qual-
ity assurance programs conducted under this 
subsection measure and report on disparities in 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00249
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
250 
the amount and quality of health care services 
furnished to racial and ethnic minorities. 
‘‘(B) CONTENTS OF REPORT.—Each such re-
port shall include the following: 
‘‘(i) A description of the means by 
which such programs focus on such racial 
and ethnic minorities. 
‘‘(ii) An evaluation of the impact of 
such programs on eliminating health dis-
parities and on improving health outcomes, 
continuity and coordination of care, man-
agement of chronic conditions, and con-
sumer satisfaction. 
‘‘(iii) Recommendations on ways to re-
duce clinical outcome disparities among ra-
cial and ethnic minorities. 
‘‘(iv) Data for each MA plan from 
HEDIS and other source reporting the dis-
parities in the amount and quality of 
health services furnished to racial and eth-
nic minorities.’’. 
SEC. 423. STRENGTHENING AUDIT AUTHORITY. 
(a) FOR PART C PAYMENTS RISK ADJUSTMENT.—Sec-
tion 1857(d)(1) of the Social Security Act (42 U.S.C. 
1395w–27(d)(1)) is amended by inserting after ‘‘section 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00250
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
251 
1858(c))’’ the following: ‘‘, and data submitted with respect 
to risk adjustment under section 1853(a)(3)’’. 
(b) ENFORCEMENT OF AUDITS AND DEFICIENCIES.— 
(1) IN GENERAL.—Section 1857(e) of such Act is 
amended by adding at the end the following new 
paragraph: 
‘‘(5) ENFORCEMENT
OF
AUDITS
AND
DEFI-
CIENCIES.— 
‘‘(A) INFORMATION IN CONTRACT.—The Sec-
retary shall require that each contract with a 
Medicare Part C organization under this section 
shall include terms that inform the organization 
of the provisions in subsection (d). 
‘‘(B) ENFORCEMENT AUTHORITY.—The Sec-
retary is authorized, in connection with con-
ducting audits and other activities under sub-
section (d), to take such actions, including pur-
suit of financial recoveries, necessary to address 
deficiencies identified in such audits or other ac-
tivities.’’. 
(2) APPLICATION UNDER PART D.—For provision 
applying the amendment made by paragraph (1) to 
prescription drug plans under part D, see section 
1860D–12(b)(3)(D) of the Social Security Act. 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00251
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
252 
(c) EFFECTIVE DATE.—The amendments made by this 
section shall take effect the date of the enactment of this 
Act and shall apply to audits and activities conducted for 
contract years beginning on or after January 1, 2009. 
SEC. 424. IMPROVING RISK ADJUSTMENT FOR MA PAY-
MENTS. 
(a) IN GENERAL.—Not later than 1 year after the date 
of the enactment of this Act, the Secretary of Health and 
Human Services shall submit to Congress a report that 
evaluates the adequacy of the Medicare Advantage risk ad-
justment system under section 1853(a)(1)(C) of the Social 
Security Act (42 U.S.C. 1395–23(a)(1)(C)). 
(b) PARTICULARS.—The report under subsection (a) 
shall include an evaluation of at least the following: 
(1) The need and feasibility of improving the 
adequacy of the risk adjustment system in predicting 
costs for beneficiaries with co-morbid conditions and 
associated cognitive impairments. 
(2) The need and feasibility of including further 
gradations of diseases and conditions (such as the de-
gree of severity of congestive heart failure). 
(3) The feasibility of measuring difference in 
coding over time between Medicare part C plans and 
the medicare traditional fee-for-service program and, 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00252
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS
253 
to the extent this difference exists, the options for ad-
dressing it. 
(4) The feasibility and value of including part D 
and other drug utilization data in the risk adjust-
ment model. 
SEC. 425. ELIMINATING SPECIAL TREATMENT OF PRIVATE 
FEE-FOR-SERVICE PLANS. 
(a) ELIMINATION OF EXTRA BILLING PROVISION.— 
Section 1852(k)(2) of the Social Security Act (42 U.S.C. 
1395w–22(k)(2)) is amended— 
(1) in subparagraph (A)(i), by striking ‘‘115 
percent’’ and inserting ‘‘100 percent’’; and 
(2) in subparagraph (C)(i), by striking ‘‘includ-
ing any liability for balance billing consistent with 
this subsection)’’. 
(b) 
REVIEW
OF
BID
INFORMATION.—Section 
1854(a)(6)(B) of such Act (42 U.S.C. 1395w–24(a)(6)(B)) 
is amended— 
(1) in clause (i), by striking ‘‘clauses (iii) and 
(iv)’’ and inserting ‘‘clause (iii)’’; and 
(2) by striking clause (iv). 
(c) EFFECTIVE DATE.—The amendments made by this 
section shall apply to contract years beginning with 2009. 
VerDate Aug 31 2005 
02:09 Aug 02, 2007
Jkt 059200
PO 00000
Frm 00253
Fmt 6652
Sfmt 6203
E:\BILLS\H3162.RH
H3162
bajohnson on PROD1PC69 with BILLS