Source: https://www.govregs.com/uscode/42/1395w%E2%80%9328
Timestamp: 2020-07-10 18:18:39
Document Index: 790171121

Matched Legal Cases: ['§\u202f1395', '§\u202f1859', '§\u202f4001', '§\u202f1000', '§\u202f523', '§\u202f221', '§\u202f108', '§\u202f162', '§\u202f3205', '§\u202f607', '§\u202f1107', '§\u202f107', '§\u202f206', '§\u202f17006', '§\u202f50311', '§\u202f6063']

42 USC 1395w-28 - Definitions; miscellaneous provisions
§ 1395w-29. Repealed.
Definitions relating to Medicare+Choice organizations
Medicare+Choice organization
Definitions relating to Medicare+Choice plans
The term “Medicare+Choice private fee-for-service plan” means a Medicare+Choice plan that—
The term “MSA plan” means a Medicare+ÐChoice plan that—
The amount of annual deductible under an MSA plan—
MA regional plan
The term “MA regional plan” means an MA plan described in section 1395w–21(a)(2)(A)(i) of this title—
MA local plan
The term “special needs individual” means an MA eligible individual who—
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—
on or after January 1, 2022, have one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits 1
So in original. Probably should be “that are life threatening or significantly limit”.
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).
Other references to other terms
Medicare+Choice payment area
National per capita Medicare+Choice growth percentage
Medicare+Choice monthly basic beneficiary premium; Medicare+Choice monthly supplemental beneficiary premium
The terms “Medicare+Choice monthly basic beneficiary premium” and “Medicare+Choice monthly supplemental beneficiary premium” are defined in section 1395w–24(a)(2) of this title.
MA local area
Coordinated acute and long-term care benefits under Medicare+Choice plan
Restriction on enrollment for certain Medicare+Choice plans
Medicare+Choice religious fraternal benefit society plan described
For 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—
“Religious fraternal benefit society” defined
For purposes of paragraph (2)(A), a “religious fraternal benefit society” described in this section is an organization that—
Requirements regarding enrollment in specialized MA plans for special needs individuals
Additional requirements for institutional SNPS
Additional requirements for dual SNPS
Each individual that enrolls in the plan on or after January 1, 2010, is a special needs individuals 2
Additional requirements for severe or disabling chronic condition SNPS
Care management requirements for all SNPs
Subject to subparagraph (B), the requirements described in this paragraph are that the organization offering a specialized MA plan for special needs individuals—
Transition and exception regarding restriction on enrollment
Subject to subparagraph (C), the Secretary shall establish procedures for the transition of applicable individuals to—
For purposes of clause (i), the term “applicable individual” means an individual who—
Timeline for initial transition
Authority to require special needs plans be NCQA approved
The 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—
basic resources for States interested in exploring such plans as a platform for integration, such as a model contract or other tools to achieve those goals.
Suspension of enrollment for failure to meet requirements during initial period
Inclusion of certain conditions
Special rules for senior housing facility plans
Medicare Advantage senior housing facility plan described
For purposes of this subsection, a Medicare Advantage senior housing facility plan is a Medicare Advantage plan that—
National testing of Medicare Advantage Value-Based Insurance Design model
In implementing the Medicare Advantage Value-Based Insurance Design model that is being tested under section 1315a(b) of this title
Not later than 2 years after October 24, 2018, the Secretary shall, after consultation with stakeholders, establish a secure internet website portal (or other successor technology) that would allow a secure path for communication between the Secretary, MA plans under this part, prescription drug plans under part D, and an eligible entity with a contract under section 1395ddd of this title (such as a Medicare drug integrity contractor or an entity responsible for carrying out program integrity activities under this part and part D) for the purpose of enabling through such portal (or other successor technology)—
the referral by such plans of substantiated or suspicious activities, as defined by the Secretary, of a provider of services (including a prescriber) or supplier related to fraud, waste, and abuse for initiating or assisting investigations conducted by the eligible entity; and
Providers of services and suppliers who are the subject of an active exclusion under section 1320a–7 of this title or who are subject to a suspension of payment under this subchapter pursuant to section 1395y(o) of this title or otherwise.
Providers of services and suppliers who are the subject of an active revocation of participation under this subchapter, including for not satisfying conditions of participation.
In the case of such a plan that makes a referral under subparagraph (A)(i) through the portal (or other successor technology) with respect to activities of substantiated or suspicious activities of fraud, waste, or abuse of a provider of services (including a prescriber) or supplier, if such provider (including a prescriber) or supplier has been the subject of an administrative action under this subchapter or subchapter XI with respect to similar activities, a notification to such plan of such action so taken.
Beginning not later than 2 years after October 24, 2018, the Secretary shall make available to MA plans under this part and prescription drug plans under part D in a timely manner (but no less frequently than quarterly) and using information submitted to an entity described in paragraph (1) through the portal (or other successor technology) described in such paragraph or pursuant to section 1395ddd of this title, information on fraud, waste, and abuse schemes and trends in identifying suspicious activity. Information included in each such report shall—
(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; Pub. L. 115–271, title VI, § 6063(a), Oct. 24, 2018, 132 Stat. 3987.)
cite as: 42 USC 1395w-28