42 U.S.C. § 1395cc-2 : US Code - Section 1395CC-2: Provisions for administration of demonstration program

Search 42 U.S.C. § 1395cc-2 : US Code - Section 1395CC-2: Provisions for administration of demonstration program

(a) General administrative authority
(1) Beneficiary eligibility
Except as otherwise provided by the Secretary, an individual
shall only be eligible to receive benefits under the program
under section 1395cc-1 of this title (in this section referred to
as the "demonstration program") if such individual -
(A) is enrolled under the program under part B of this
subchapter and entitled to benefits under part A of this
subchapter; and
(B) is not enrolled in a Medicare+Choice plan under part C of
this subchapter, an eligible organization under a contract
under section 1395mm of this title (or a similar organization
operating under a demonstration project authority), an
organization with an agreement under section 1395l(a)(1)(A) of
this title, or a PACE program under section 1395eee of this
title.
(2) Secretary's discretion as to scope of program
The Secretary may limit the implementation of the demonstration
program to -
(A) a geographic area (or areas) that the Secretary
designates for purposes of the program, based upon such
criteria as the Secretary finds appropriate;
(B) a subgroup (or subgroups) of beneficiaries or individuals
and entities furnishing items or services (otherwise eligible
to participate in the program), selected on the basis of the
number of such participants that the Secretary finds consistent
with the effective and efficient implementation of the program;
(C) an element (or elements) of the program that the
Secretary determines to be suitable for implementation; or
(D) any combination of any of the limits described in
subparagraphs (A) through (C).
(3) Voluntary receipt of items and services
Items and services shall be furnished to an individual under
the demonstration program only at the individual's election.
(4) Agreements
The Secretary is authorized to enter into agreements with
individuals and entities to furnish health care items and
services to beneficiaries under the demonstration program.
(5) Program standards and criteria
The Secretary shall establish performance standards for the
demonstration program including, as applicable, standards for
quality of health care items and services, cost-effectiveness,
beneficiary satisfaction, and such other factors as the Secretary
finds appropriate. The eligibility of individuals or entities for
the initial award, continuation, and renewal of agreements to
provide health care items and services under the program shall be
conditioned, at a minimum, on performance that meets or exceeds
such standards.
(6) Administrative review of decisions affecting individuals and
entities furnishing services
An individual or entity furnishing services under the
demonstration program shall be entitled to a review by the
program administrator (or, if the Secretary has not contracted
with a program administrator, by the Secretary) of a decision not
to enter into, or to terminate, or not to renew, an agreement
with the entity to provide health care items or services under
the program.
(7) Secretary's review of marketing materials
An agreement with an individual or entity furnishing services
under the demonstration program shall require the individual or
entity to guarantee that it will not distribute materials that
market items or services under the program without the
Secretary's prior review and approval.
(8) Payment in full
(A) In general
Except as provided in subparagraph (B), an individual or
entity receiving payment from the Secretary under a contract or
agreement under the demonstration program shall agree to accept
such payment as payment in full, and such payment shall be in
lieu of any payments to which the individual or entity would
otherwise be entitled under this subchapter.
(B) Collection of deductibles and coinsurance
Such individual or entity may collect any applicable
deductible or coinsurance amount from a beneficiary.
(b) Contracts for program administration
(1) In general
The Secretary may administer the demonstration program through
a contract with a program administrator in accordance with the
provisions of this subsection.
(2) Scope of program administrator contracts
The Secretary may enter into such contracts for a limited
geographic area, or on a regional or national basis.
(3) Eligible contractors
The Secretary may contract for the administration of the
program with -
(A) an entity that, under a contract under section 1395h or
1395u of this title, determines the amount of and makes
payments for health care items and services furnished under
this subchapter; or
(B) any other entity with substantial experience in managing
the type of program concerned.
(4) Contract award, duration, and renewal
(A) In general
A contract under this subsection shall be for an initial term
of up to three years, renewable for additional terms of up to
three years.
(B) Noncompetitive award and renewal for entities administering
part A or part B payments
The Secretary may enter or renew a contract under this
subsection with an entity described in paragraph (3)(A) without
regard to the requirements of section 5 of title 41.
(5) Applicability of Federal Acquisition Regulation
The Federal Acquisition Regulation shall apply to program
administration contracts under this subsection.
(6) Performance standards
The Secretary shall establish performance standards for the
program administrator including, as applicable, standards for the
quality and cost-effectiveness of the program administered, and
such other factors as the Secretary finds appropriate. The
eligibility of entities for the initial award, continuation, and
renewal of program administration contracts shall be conditioned,
at a minimum, on performance that meets or exceeds such
standards.
(7) Functions of program administrator
A program administrator shall perform any or all of the
following functions, as specified by the Secretary:
(A) Agreements with entities furnishing health care items and
services
Determine the qualifications of entities seeking to enter or
renew agreements to provide services under the demonstration
program, and as appropriate enter or renew (or refuse to enter
or renew) such agreements on behalf of the Secretary.
(B) Establishment of payment rates
Negotiate or otherwise establish, subject to the Secretary's
approval, payment rates for covered health care items and
services.
(C) Payment of claims or fees
Administer payments for health care items or services
furnished under the program.
(D) Payment of bonuses
Using such guidelines as the Secretary shall establish, and
subject to the approval of the Secretary, make bonus payments
as described in subsection (c)(2)(B) of this section to
entities furnishing items or services for which payment may be
made under the program.
(E) Oversight
Monitor the compliance of individuals and entities with
agreements under the program with the conditions of
participation.
(F) Administrative review
Conduct reviews of adverse determinations specified in
subsection (a)(6) of this section.
(G) Review of marketing materials
Conduct a review of marketing materials proposed by an entity
furnishing services under the program.
(H) Additional functions
Perform such other functions as the Secretary may specify.
(8) Limitation of liability
The provisions of section 1320c-6(b) of this title shall apply
with respect to activities of contractors and their officers,
employees, and agents under a contract under this subsection.
(9) Information sharing
Notwithstanding section 1306 of this title and section 552a of
title 5, the Secretary is authorized to disclose to an entity
with a program administration contract under this subsection such
information (including medical information) on individuals
receiving health care items and services under the program as the
entity may require to carry out its responsibilities under the
contract.
(c) Rules applicable to both program agreements and program
administration contracts
(1) Records, reports, and audits
The Secretary is authorized to require entities with agreements
to provide health care items or services under the demonstration
program, and entities with program administration contracts under
subsection (b) of this section, to maintain adequate records, to
afford the Secretary access to such records (including for audit
purposes), and to furnish such reports and other materials
(including audited financial statements and performance data) as
the Secretary may require for purposes of implementation,
oversight, and evaluation of the program and of individuals' and
entities' effectiveness in performance of such agreements or
contracts.
(2) Bonuses
Notwithstanding any other provision of law, but subject to
subparagraph (B)(ii), the Secretary may make bonus payments under
the demonstration program from the Federal Health Insurance Trust
Fund and the Federal Supplementary Medical Insurance Trust Fund
in amounts that do not exceed the amounts authorized under the
program in accordance with the following:
(A) Payments to program administrators
The Secretary may make bonus payments under the program to
program administrators.
(B) Payments to entities furnishing services
(i) In general
Subject to clause (ii), the Secretary may make bonus
payments to individuals or entities furnishing items or
services for which payment may be made under the
demonstration program, or may authorize the program
administrator to make such bonus payments in accordance with
such guidelines as the Secretary shall establish and subject
to the Secretary's approval.
(ii) Limitations
The Secretary may condition such payments on the
achievement of such standards related to efficiency,
improvement in processes or outcomes of care, or such other
factors as the Secretary determines to be appropriate.
(3) Antidiscrimination limitation
The Secretary shall not enter into an agreement with an entity
to provide health care items or services under the demonstration
program, or with an entity to administer the program, unless such
entity guarantees that it will not deny, limit, or condition the
coverage or provision of benefits under the program, for
individuals eligible to be enrolled under such program, based on
any health status-related factor described in section 300gg-
1(a)(1) of this title.
(d) Limitations on judicial review
The following actions and determinations with respect to the
demonstration program shall not be subject to review by a judicial
or administrative tribunal:
(1) Limiting the implementation of the program under subsection
(a)(2) of this section.
(2) Establishment of program participation standards under
subsection (a)(5) of this section or the denial or termination
of, or refusal to renew, an agreement with an entity to provide
health care items and services under the program.
(3) Establishment of program administration contract
performance standards under subsection (b)(6) of this section,
the refusal to renew a program administration contract, or the
noncompetitive award or renewal of a program administration
contract under subsection (b)(4)(B) of this section.
(4) Establishment of payment rates, through negotiation or
otherwise, under a program agreement or a program administration
contract.
(5) A determination with respect to the program (where
specifically authorized by the program authority or by subsection
(c)(2) of this section) -
(A) as to whether cost savings have been achieved, and the
amount of savings; or
(B) as to whether, to whom, and in what amounts bonuses will
be paid.
(e) Application limited to parts A and B
None of the provisions of this section or of the demonstration
program shall apply to the programs under part C of this
subchapter.
(f) Reports to Congress
Not later than two years after December 21, 2000, and biennially
thereafter for six years, the Secretary shall report to Congress on
the use of authorities under the demonstration program. Each report
shall address the impact of the use of those authorities on
expenditures, access, and quality under the programs under this
subchapter.