Source: http://www.law.cornell.edu/uscode/text/42/1395w-25?quicktabs_8=4
Timestamp: 2013-06-19 04:21:54
Document Index: 360030225

Matched Legal Cases: ['§ 1395', '§ 1395', '§ 1395', '§ 1855', '§ 4001', 'art 406']

42 USC § 1395w–25 - Organizational and financial requirements for Medicare Choice organizations; provider-sponsored organizations | Title 42 - The Public Health and Welfare | U.S. Code | LII / Legal Information Institute
USC › Title 42 › Chapter 7 › Subchapter XVIII › Part C › § 1395w–25	prevnext
42 USC § 1395w–25 - Organizational and financial requirements for Medicare Choice organizations; provider-sponsored organizations
Organized and licensed under State law (1)
In general Subject to paragraphs (2) and (3), a Medicare Choice organization shall be organized and licensed under State law as a risk-bearing entity eligible to offer health insurance or health benefits coverage in each State in which it offers a Medicare Choice plan.
Special exception for provider-sponsored organizations (A)
In general In the case of a provider-sponsored organization that seeks to offer a Medicare Choice plan in a State, the Secretary shall waive the requirement of paragraph (1) that the organization be licensed in that State if—
Failure to act on licensure application on a timely basis The ground for approval of such a waiver application described in this subparagraph is that the State has failed to complete action on a licensing application of the organization within 90 days of the date of the State’s receipt of a substantially complete application. No period before August 5, 1997, shall be included in determining such 90-day period.
Denial of application based on discriminatory treatment The ground for approval of such a waiver application described in this subparagraph is that the State has denied such a licensing application and—
the State requires the organization, as a condition of licensure, to offer any product or plan other than a Medicare Choice plan.
Denial of application based on application of solvency requirements With respect to waiver applications filed on or after the date of publication of solvency standards under section 1395w–26
(a) of this title, the ground for approval of such a waiver application described in this subparagraph is that the State has denied such a licensing application based (in whole or in part) on the organization’s failure to meet applicable solvency requirements and—
such requirements are not the same as the solvency standards established under section 1395w–26
the State has imposed as a condition of approval of the license documentation or information requirements relating to solvency or other material requirements, procedures, or standards relating to solvency that are different from the requirements, procedures, and standards applied by the Secretary under subsection (d)(2) of this section.
For purposes of this paragraph, the term “solvency requirements” means requirements relating to solvency and other matters covered under the standards established under section 1395w–26
Treatment of waiver In the case of a waiver granted under this paragraph for a provider-sponsored organization with respect to a State—
Prompt action on application The Secretary shall grant or deny such a waiver application within 60 days after the date the Secretary determines that a substantially complete waiver application has been filed. Nothing in this section shall be construed as preventing an organization which has had such a waiver application denied from submitting a subsequent waiver application.
Application and enforcement of State consumer protection and quality standards (i)
are generally applicable to other Medicare Choice organizations and plans in the State; and
Such standards shall not include any standard preempted under section 1395w–26
(b)(3)(B) of this title.
In the case of such a waiver granted to an organization with respect to a State, the Secretary shall incorporate the requirement that the organization (and Medicare Choice plans it offers) comply with standards under clause (i) as part of the contract between the Secretary and the organization under section 1395w–27 of this title.
In the case of such a waiver granted to an organization with respect to a State, the Secretary may enter into an agreement with the State under which the State agrees to provide for monitoring and enforcement activities with respect to compliance of such an organization and its Medicare Choice plans with such standards. Such monitoring and enforcement shall be conducted by the State in the same manner as the State enforces such standards with respect to other Medicare Choice organizations and plans, without discrimination based on the type of organization to which the standards apply. Such an agreement shall specify or establish mechanisms by which compliance activities are undertaken, while not lengthening the time required to review and process applications for waivers under this paragraph.
Report By not later than December 31, 2001, the Secretary shall submit to the Committee on Ways and Means and the Committee on Commerce of the House of Representatives and the Committee on Finance of the Senate a report regarding whether the waiver process under this paragraph should be continued after December 31, 2002. In making such recommendation, the Secretary shall consider, among other factors, the impact of such process on beneficiaries and on the long-term solvency of the program under this subchapter.
Licensure does not substitute for or constitute certification The fact that an organization is licensed in accordance with paragraph (1) does not deem the organization to meet other requirements imposed under this part.
Assumption of full financial risk The Medicare Choice organization shall assume full financial risk on a prospective basis for the provision of the health care services for which benefits are required to be provided under section 1395w–22
(a)(1) of this title, except that the organization—
Certification of provision against risk of insolvency for unlicensed PSOs (1)
In general Each Medicare Choice organization that is a provider-sponsored organization, that is not licensed by a State under subsection (a) of this section, and for which a waiver application has been approved under subsection (a)(2) of this section, shall meet standards established under section 1395w–26
(a) of this title relating to the financial solvency and capital adequacy of the organization.
Certification process for solvency standards for PSOs The Secretary shall establish a process for the receipt and approval of applications of a provider-sponsored organization described in paragraph (1) for certification (and periodic recertification) of the organization as meeting such solvency standards. Under such process, the Secretary shall act upon such a certification application not later than 60 days after the date the application has been received.
“Provider-sponsored organization” defined (1)
In general In this part, the term “provider-sponsored organization” means a public or private entity—
Substantial proportion In defining what is a “substantial proportion” for purposes of paragraph (1)(B), the Secretary—
Affiliation For purposes of this subsection, a provider is “affiliated” with another provider if, through contract, ownership, or otherwise—
Control For purposes of paragraph (3), control is presumed to exist if one party, directly or indirectly, owns, controls, or holds the power to vote, or proxies for, not less than 51 percent of the voting rights or governance rights of another.
“Health care provider” defined In this subsection, the term “health care provider” means—
Regulations The Secretary shall issue regulations to carry out this subsection.
(Aug. 14, 1935, ch. 531, title XVIII, § 1855, as added Pub. L. 105–33, title IV, § 4001,Aug. 5, 1997, 111 Stat. 312.)
The Internal Revenue Code of 1986, referred to in subsec. (d)(3)(B), (D), is classified generally to Title 26, Internal Revenue Code.
This is a list of parts within the Code of Federal Regulations for which this US Code section provides rulemaking authority.This list is taken from the Parallel Table of Authorities and Rules provided by GPO [Government Printing Office].It is not guaranteed to be accurate or up-to-date, though we do refresh the database weekly. More limitations on accuracy are described at the GPO site.42 CFR - Title 42—Public Health42 CFR Part 406 - HOSPITAL INSURANCE ELIGIBILITY AND ENTITLEMENT