Source: https://www.law.cornell.edu/uscode/text/42/1395w%E2%80%9328
Timestamp: 2020-01-18 08:34:23
Document Index: 611468133

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42 U.S. Code § 1395w–28 - Definitions; miscellaneous provisions | US Law | LII / Legal Information Institute
U.S. Code › Title 42 › Chapter 7 › Subchapter XVIII › Part C › § 1395w–28
42 U.S. Code § 1395w–28 - Definitions; miscellaneous provisions
§ 1395w–28.
Definitions; miscellaneous provisions
(a) Definitions relating to Medicare+Choice organizationsIn this part—
The term “Medicare+Choice organization” means a public or private entity that is certified under section 1395w–26 of this title as meeting the requirements and standards of this part for such an organization.
The term “provider-sponsored organization” is defined in section 1395w–25(d)(1) of this title.
The term “Medicare+Choice plan” means health benefits coverage offered under a policy, contract, or plan by a Medicare+Choice organization pursuant to and in accordance with a contract under section 1395w–27 of this title.
(2) Medicare+Choice private fee-for-service planThe term “Medicare+Choice private fee-for-serviceplan” means a Medicare+Choice plan that—
(A) In generalThe term “MSA plan” means a Medicare+ÐChoice plan that—
provides reimbursement for at least the items and services described in section 1395w–22(a)(1) of this title in a year but only after the enrollee incurs countable expenses (as specified under the plan) equal to the amount of an annual deductible (described in subparagraph (B));
counts as such expenses (for purposes of such deductible) at least all amounts that would have been payable under parts A and B, and that would have been payable by the enrollee as deductibles, coinsurance, or copayments, if the enrollee had elected to receive benefits through the provisions of such parts; and
(iii) provides, after such deductible is met for a year and for all subsequent expenses for items and services referred to in clause (i) in the year, for a level of reimbursement that is not less than—
100 percent of the amounts that would have been paid (without regard to any deductibles or coinsurance) under parts A and B with respect to such expenses,
(B) DeductibleThe amount of annual deductible under an MSA plan—
for a subsequent contract year shall be not more than the maximum amount of such deductible for the previous contract year under this subparagraph increased by the national per capita Medicare+Choice growth percentage under section 1395w–23(c)(6) of this title for the year.
(4) MA regional planThe term “MA regional plan” means an MA plan described in section 1395w–21(a)(2)(A)(i) of this title—
The term “MA local plan” means an MA plan that is not an MA regional plan.
The term “specialized MA plan for special needs individuals” means an MA plan that exclusively serves special needs individuals (as defined in subparagraph (B)) and that, as of January 1, 2010, meets the applicable requirements of paragraph (2), (3), or (4) of subsection (f), as the case may be.
(B) Special needs individualThe term “special needs individual” means an MA eligible individual who—
is entitled to medical assistance under a State plan under subchapter XIX; or
(iii) meets such requirements as the Secretary may determine would benefit from enrollment in such a specialized MA plan described in subparagraph (A) for individuals with severe or disabling chronic conditions who—
before January 1, 2022, have one or more comorbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care; and
on or after January 1, 2022, have one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits overall health or function, have a high risk of hospitalization or other adverse health outcomes, and require intensive care coordination and that is listed under subsection (f)(9)(A).
The term “Medicare+Choice eligible individual” is defined in section 1395w–21(a)(3) of this title.
The term “Medicare+Choice payment area” is defined in section 1395w–23(d) of this title.
The “national per capita Medicare+Choice growth percentage” is defined in section 1395w–23(c)(6) of this title.
The terms “Medicare+Choice monthly basicbeneficiary premium” and “Medicare+Choice monthly supplemental beneficiary premium” are defined in section 1395w–24(a)(2) of this title.
The term “MA local area” is defined in section 1395w–23(d)(2) of this title.
(2) Medicare+Choice religious fraternal benefit society plan describedFor purposes of this subsection, a Medicare+Choice religious fraternal benefit society plan described in this paragraph is a Medicare+Choice plan described in section 1395w–21(a)(2) of this title that—
(3) “Religious fraternal benefit society” definedFor purposes of paragraph (2)(A), a “religious fraternal benefit society” described in this section is an organization that—
offers, in addition to a Medicare+ÐChoice religious fraternal benefit society plan, health coverage to individuals not entitled to benefits under this subchapter who are members of such church, convention, or group; and
(2) Additional requirements for institutional SNPSIn the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(i), the applicable requirements described in this paragraph are as follows:
(A) Each individual that enrolls in the plan on or after January 1, 2010, is a special needs individuals described in subsection (b)(6)(B)(i). In the case of an individual who is living in the community but requires an institutional level of care, such individual shall not be considered a special needs individual described in subsection (b)(6)(B)(i) unless the determination that the individual requires an institutional level of care was made—
(3) Additional requirements for dual SNPSIn the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii), the applicable requirements described in this paragraph are as follows:
Each individual that enrolls in the plan on or after January 1, 2010, is a special needs individuals [1] described in subsection (b)(6)(B)(ii).
(C) The plan provides each prospective enrollee, prior to enrollment, with a comprehensive written statement (using standardized content and format established by the Secretary) that describes—
The plan meets the requirements applicable under paragraph (8).
(4) Additional requirements for severe or disabling chronic condition SNPSIn the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(iii), the applicable requirements described in this paragraph are as follows:
(A) In generalSubject to subparagraph (B), the requirements described in this paragraph are that the organization offering a specialized MA plan for special needs individuals—
(ii) with respect to each individual enrolled in the plan—
(B) Improvements to care management requirements for severe or disabling chronic condition SNPsFor 2020 and subsequent years, in the case of a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(iii), the requirements described in this paragraph include the following:
The interdisciplinary team under subparagraph (A)(ii)(III) includes a team of providers with demonstrated expertise, including training in an applicable specialty, in treating individuals similar to the targeted population of the plan.
Requirements developed by the Secretary to provide face-to-face encounters with individuals enrolled in the plan not less frequently than on an annual basis.
As part of the model of care under clause (i) of subparagraph (A), the results of the initial assessment and annual reassessment under clause (ii)(I) of such subparagraph of each individual enrolled in the plan are addressed in the individual’s individualized care plan under clause (ii)(II) of such subparagraph.
As part of the annual evaluation and approval of such model of care, the Secretary shall take into account whether the plan fulfilled the previous year’s goals (as required under the model of care).
(A) In generalSubject to subparagraph (C), the Secretary shall establish procedures for the transition of applicable individuals to—
the original medicare fee-for-serviceprogram under parts A and B.
(B) Applicable individualsFor purposes of clause (i), the term ‘applicable individual’ means an individual who—
(A) Designated contactThe Secretary, acting through the Federal Coordinated Health Care Office established under section 1315b of this title, shall serve as a dedicated point of contact for States to address misalignments that arise with the integration of specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) under this paragraph and, consistent with such role, shall establish—
a uniform process for disseminating to State Medicaid agencies information under this subchapter impacting contracts between such agencies and such plans under this subsection; and
basicresources for States interested in exploring such plans as a platform for integration, such as a model contract or other tools to achieve those goals.
(ii) ProceduresThe procedures established under clause (i) shall be included in the plan contract under paragraph (3)(D) and shall—
adopt the provisions for the enrollee that are most protective for the enrollee and, to the extent feasible as determined by the Secretary, are compatible with unified timeframes and consolidated access to external review under an integrated process;
take into account differences in State plans under subchapter XIX to the extent necessary;
be easily navigable by an enrollee; and
include the elements described in clause (iii), as applicable.
(iii) Elements describedBoth unified appeals and unified grievance procedures shall include, as applicable, the following elements described in this clause:
Single written notification of all applicable grievances and appeal rights under this subchapter and subchapter XIX. For purposes of this subparagraph, the Secretary may waive the requirements under section 1395w–22(g)(1)(B) of this title when the specialized MA plan covers items or services under this part or under subchapter XIX.
Single pathways for resolution of any grievance or appeal related to a particular item or service provided by specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) under this subchapter and subchapter XIX.
Notices written in plain language and available in a language and format that is accessible to the enrollee, including in non-English languages that are prevalent in the service area of the specialized MA plan.
Unified timeframes for grievances and appeals processes, such as an individual’s filing of a grievance or appeal, a plan’s acknowledgment and resolution of a grievance or appeal, and notification of decisions with respect to a grievance or appeal.
Requirements for how the plan must process, track, and resolve grievances and appeals, to ensure beneficiaries are notified on a timely basis of decisions that are made throughout the grievance or appeals process and are able to easily determine the status of a grievance or appeal.
(i) In generalFor 2021 and subsequent years, a specialized MA plan for special needs individuals described in subsection (b)(6)(B)(ii) shall meet one or more of the following requirements, to the extent permitted under State law, for integration of benefits under this subchapter and subchapter XIX:
The specialized MA plan must meet the requirements of contracting with the State Medicaid agency described in paragraph (3)(D) in addition to coordinating long-term services and supports or behavioral health services, or both, by meeting an additional minimum set of requirements determined by the Secretary through the Federal Coordinated Health Care Office established under section 1315b of this title based on input from stakeholders, such as notifying the State in a timely manner of hospitalizations, emergency room visits, and hospital or nursing home discharges of enrollees, assigning one primary care provider for each enrollee, or sharing data that would benefit the coordination of items and services under this subchapter and the State plan under subchapter XIX. Such minimum set of requirements must be included in the contract of the specialized MA plan with the State Medicaid agency under such paragraph.
The specialized MA plan must meet the requirements of a fully integrated plan described in section 1395w–23(a)(1)(B)(iv)(II) of this title (other than the requirement that the plan have similar average levels of frailty, as determined by the Secretary, as the PACE program), or enter into a capitated contract with the State Medicaid agency to provide long-term services and supports or behavioral health services, or both.
In the case of a specialized MA plan that is offered by a parent organization that is also the parent organization of a Medicaid managed care organization providing long term services and supports or behavioral services under a contract under section 1396b(m) of this title, the parent organization must assume clinical and financial responsibility for benefits provided under this subchapter and subchapter XIX with respect to any individual who is enrolled in both the specialized MA plan and the Medicaid managed care organization.
(i) In generalNot later than March 15, 2022, and, subject to clause (iii), biennially thereafter through 2032, the Medicare Payment Advisory Commission established under section 1395b–6 of this title, in consultation with the Medicaid and CHIP Payment and Access Commission established under section 1396 of this title, shall conduct (and submit to the Secretary and the Committees on Ways and Means and Energy and Commerce of the House of Representatives and the Committee on Finance of the Senate a report on) a study to determine how specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii) perform among each other based on data from Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, reported on the plan level, as required under section 1395w–22(e)(3) of this title (or such other measures or data sources that are available and appropriate, such as encounter data and Consumer Assessment of Healthcare Providers and Systems data, as specified by such Commissions as enabling an accurate evaluation under this subparagraph). Such study shall include, as feasible, the following comparison groups of specialized MA plans for special needs individuals described in subsection (b)(6)(B)(ii):
A comparison group of such plans that are described in subparagraph (D)(i)(I).
A comparison group of such plans that are described in subparagraph (D)(i)(II).
A comparison group of such plans operating within the Financial Alignment Initiative demonstration for the period for which such plan is so operating and the demonstration is in effect, and, in the case that an integration option that is not with respect to specialized MA plans for special needs individuals is established after the conclusion of the demonstration involved.
A comparison group of such plans that are described in subparagraph (D)(i)(III).
A comparison group of MA plans, as feasible, not described in a previous subclause of this clause, with respect to the performance of such plans for enrollees who are special needs individuals described in subsection (b)(6)(B)(ii).
(A) In generalNot later than December 31, 2020, and every 5 years thereafter, subject to subparagraphs (B) and (C), the Secretary shall convene a panel of clinical advisors to establish and update a list of conditions that meet each of the following criteria:
Conditions that meet the definition of a severe or disabling chronic condition under subsection (b)(6)(B)(iii) on or after January 1, 2022.
(ii) Conditions that require prescription drugs, providers, and models of care that are unique to the specific population of enrollees in a specialized MA plan for special needs individuals described in such subsection on or after such date and—
as a result of access to, and enrollment in, such a specialized MA plan for special needs individuals, individuals with such condition would have a reasonable expectation of slowing or halting the progression of the disease, improving health outcomes and decreasing overall costs for individuals diagnosed with such condition compared to available options of care other than through such a specialized MA plan for special needs individuals; or
have a low prevalence in the general population of beneficiaries under this subchapter or a disproportionally high per-beneficiary cost under this subchapter.
In the case of a Medicare Advantage senior housing facilityplan described in paragraph (2), notwithstanding any other provision of this part to the contrary and in accordance with regulations of the Secretary, the service area of such plan may be limited to a senior housing facility in a geographic area.
(2) Medicare Advantage senior housing facility plan describedFor purposes of this subsection, a Medicare Advantage senior housing facilityplan is a Medicare Advantage plan that—
restricts enrollment of individuals under this part to individuals who reside in a continuing care retirement community (as defined in section 1395w–22(l)(4)(B) of this title);
(Aug. 14, 1935, ch. 531, title XVIII, § 1859, as added Pub. L. 105–33, title IV, § 4001, Aug. 5, 1997, 111 Stat. 325; amended Pub. L. 106–113, div. B, § 1000(a)(6) [title V, § 523], Nov. 29, 1999, 113 Stat. 1536, 1501A–387; Pub. L. 108–173, title II, §§ 221(b)(1), (d)(2), 231(b), (c), Dec. 8, 2003, 117 Stat. 2180, 2193, 2207, 2208; Pub. L. 110–173, title I, § 108(a), Dec. 29, 2007, 121 Stat. 2496; Pub. L. 110–275, title I, §§ 162(b), 164(a), (c)(1), (d)(1), (e)(1), July 15, 2008, 122 Stat. 2571–2574; Pub. L. 111–148, title III, §§ 3205(a), (c), (e), (g), 3208(a), Mar. 23, 2010, 124 Stat. 457–459; Pub. L. 112–240, title VI, § 607, Jan. 2, 2013, 126 Stat. 2349; Pub. L. 113–67, div. B, title I, § 1107, Dec. 26, 2013, 127 Stat. 1197; Pub. L. 113–93, title I, § 107, Apr. 1, 2014, 128 Stat. 1043; Pub. L. 114–10, title II, § 206, Apr. 16, 2015, 129 Stat. 145; Pub. L. 114–255, div. C, title XVII, § 17006(a)(2)(B), Dec. 13, 2016, 130 Stat. 1334; Pub. L. 115–123, div. E, title III, §§ 50311(a), (b)(1), (c), 50321, Feb. 9, 2018, 132 Stat. 192, 196, 200.)
[1]  So in original. Probably should be “individual”.
2018—Subsec. (b)(6)(B)(iii). Pub. L. 115–123, § 50311(c)(2)(A), substituted “who—
“(I) before January 1, 2022, have”
for “who have” and “care; and” for “care.”, and added subcl. (II).
Subsec. (f)(1). Pub. L. 115–123, § 50311(a), struck out “and for periods before January 1, 2019” after “the Secretary”.
Subsec. (f)(3)(F). Pub. L. 115–123, § 50311(b)(1)(A), added subpar. (F).
Subsec. (f)(5). Pub. L. 115–123, § 50311(c)(1), designated existing provisions as subpar. (A), inserted heading, substituted “Subject to subparagraph (B), the requirements” for “The requirements” redesignated former pars. (A) and (B)(i) to (iii) as cls. (i) and (ii)(I) to (III), respectively, and added par. (B).
Subsec. (f)(8). Pub. L. 115–123, § 50311(b)(1)(B), added par. (8).
Subsec. (f)(9). Pub. L. 115–123, § 50311(c)(2)(B), added par. (9).
Subsec. (h). Pub. L. 115–123, § 50321, added subsec. (h).
2016—Subsec. (b)(6). Pub. L. 114–255 struck out “may waive application of section 1395w–21(a)(3)(B) of this title in the case of an individual described in clause (i), (ii), or (iii) of this subparagraph and” after “The Secretary” in concluding provisions.
2015—Subsec. (f)(1). Pub. L. 114–10 substituted “2019” for “2017”.
2014—Subsec. (f)(1). Pub. L. 113–93 substituted “2017” for “2016”.
2013—Subsec. (f)(1). Pub. L. 113–67 substituted “2016” for “2015”.
Subsec. (f)(1). Pub. L. 112–240 substituted “2015” for “2014”.
2010—Subsec. (f)(1). Pub. L. 111–148, § 3205(a), substituted “2014” for “2011”.
Subsec. (f)(2)(C). Pub. L. 111–148, § 3205(e)(1), added subpar. (C).
Subsec. (f)(3)(E). Pub. L. 111–148, § 3205(e)(2), added subpar. (E).
Subsec. (f)(4)(C). Pub. L. 111–148, § 3205(e)(3), added subpar. (C).
Subsec. (f)(5). Pub. L. 111–148, § 3205(g), struck out “described in subsection (b)(6)(B)(i)” after “individuals” in introductory provisions.
Subsec. (f)(6), (7). Pub. L. 111–148, § 3205(c), (e)(4), added pars. (6) and (7).
Subsec. (g). Pub. L. 111–148, § 3208(a), added subsec. (g).
2008—Subsec. (b)(2). Pub. L. 110–275, § 162(b), inserted concluding provisions.
Subsec. (b)(6)(A). Pub. L. 110–275, § 164(c)(1)(A), inserted “and that, as of January 1, 2010, meets the applicable requirements of paragraph (2), (3), or (4) of subsection (f), as the case may be” before period at end.
Subsec. (b)(6)(B)(iii). Pub. L. 110–275, § 164(e)(1), inserted “who have one or more comorbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care” before period at end.
Subsec. (f). Pub. L. 110–275, § 164(c)(1)(B)(ii), (iii), designated existing provisions as par. (1), inserted par. heading, and added pars. (2) to (4).
Pub. L. 110–275, § 164(c)(1)(B)(i), amended heading generally. Prior to amendment, heading read “Restriction on enrollment for specialized MA plans for special needs individuals”.
Pub. L. 110–275, § 164(a), substituted “2011” for “2010”.
Subsec. (f)(5). Pub. L. 110–275, § 164(d)(1), added par. (5).
2007—Subsec. (f). Pub. L. 110–173 substituted “2010” for “2009”.
2003—Subsec. (b)(4), (5). Pub. L. 108–173, § 221(b)(1), added pars. (4) and (5).
Subsec. (b)(6). Pub. L. 108–173, § 231(b), added par. (6).
Subsec. (c)(5). Pub. L. 108–173, § 221(d)(2), added par. (5).
Subsec. (f). Pub. L. 108–173, § 231(c), added subsec. (f).
1999—Subsec. (e)(2). Pub. L. 106–113 substituted “section 1395w–21(a)(2) of this title” for “section 1395w–21(a)(2)(A) of this title” in introductory provisions.
Pub. L. 111–148, title III, § 3208(b), Mar. 23, 2010, 124 Stat. 460, provided that:
“The amendment made by this section [amending this section] shall take effect on January 1, 2010, and shall apply to plan years beginning on or after such date.”
Pub. L. 108–173, title II, § 231(f)(2), Dec. 8, 2003, 117 Stat. 2208, provided that:
“No later than 1 year after the date of the enactment of this Act [Dec. 8, 2003], the Secretary [of Health and Human Services] shall issue final regulations to establish requirements for special needs individuals under section 1859(b)(6)(B)(iii) of the Social Security Act [42 U.S.C. 1395w–28(b)(6)(B)(iii)], as added by subsection (b).”
Pub. L. 110–275, title I, § 164(c)(2)–(4), July 15, 2008, 122 Stat. 2573, as amended by Pub. L. 111–148, title III, § 3205(d), Mar. 23, 2010, 124 Stat. 458, provided that:
“(2)Authority to operate but no service area expansion for dual snps that do not meet certain requirements.—Notwithstanding subsection (f) of section 1859 of the Social Security Act (42 U.S.C. 1395w–28), during the period beginning on January 1, 2010, and ending on December 31, 2012, in the case of a specialized Medicare Advantage plan for special needs individuals described in subsection (b)(6)(B)(ii) of such section, as amended by this section, that does not meet the requirement described in subsection (f)(3)(D) of such section, the Secretary of Health and Human Services—
shall permit such plan to be offered under part C of title XVIII of such Act [42 U.S.C. 1395w–21 et seq.]; and
shall not permit an expansion of the service area of the plan under such part C.
“(3)Resources for state medicaid agencies.—
“(4)No requirement for contract.—
Nothing in the provisions of, or amendments made by, this subsection [amending this section] shall require a State to enter into a contract with a Medicare Advantage organization with respect to a specialized MA plan for special needs individuals described in section 1859(b)(6)(B)(ii) of the Social Security Act (42 U.S.C. 1395w–28(b)(6)(B)(ii)), as amended by this section.”
Pub. L. 110–275, title I, § 164(e)(2), July 15, 2008, 122 Stat. 2574, provided that:
“The Secretary of Health and Human Services shall convene a panel of clinical advisors to determine the conditions that meet the definition of severe and disabling chronic conditions under section 1859(b)(6)(B)(iii) of the Social Security Act (42 U.S.C. 1395w–28(b)(6)(B)(iii)), as amended by paragraph (1). The panel shall include the Director of the Agency for Healthcare Research and Quality (or the Director’s designee).”
Pub. L. 110–275, title I, § 164(h), July 15, 2008, 122 Stat. 2575, provided that:
“Nothing in the provisions of, or amendments made by, this section [amending this section and sections 1395w–22 and 1395w–27 of this title and enacting provisions set out as notes under this section and sections 1395w–21, 1395w–22, and 1395w–27 of this title] shall affect the benefits available under the Medicaid program under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] for special needs individuals described in section 1859(b)(6)(B)(ii) of such Act (42 U.S.C. 1395w–28(b)(6)(B)(ii)).”