42 U.S.C. § 1395ggg : US Code - Section 1395GGG: Medicare subvention demonstration project for military retirees

Search 42 U.S.C. § 1395ggg : US Code - Section 1395GGG: Medicare subvention demonstration project for military retirees

(a) Definitions
In this section:
(1) Administering Secretaries
The term "administering Secretaries" means the Secretary and
the Secretary of Defense acting jointly.
(2) Demonstration project; project
The terms "demonstration project" and "project" mean the
demonstration project carried out under this section.
(3) Designated provider
The term "designated provider" has the meaning given that term
in section 721(5) of the National Defense Authorization Act For
Fiscal Year 1997 (Public Law 104-201; 110 Stat. 2593; 10 U.S.C.
1073 note).
(4) Medicare-eligible military retiree or dependent
The term "medicare-eligible military retiree or dependent"
means an individual described in section 1074(b) or 1076(b) of
title 10 who -
(A) is eligible for health benefits under section 1086 of
such title by reason of subsection (c)(1) of such section;
(B)(i) is entitled to benefits under part A of this
subchapter; and
(ii) if the individual was entitled to such benefits before
July 1, 1997, received health care items or services from a
health care facility of the uniformed services before that
date, but after becoming entitled to benefits under part A of
this subchapter;
(C) is enrolled for benefits under part B of this subchapter;
and
(D) has attained age 65.
(5) Medicare health care services
The term "medicare health care services" means items or
services covered under part A or B of this subchapter.
(6) Military treatment facility
The term "military treatment facility" means a facility
referred to in section 1074(a) of title 10.
(7) TRICARE
The term "TRICARE" has the same meaning as the term "TRICARE
program" under section 711 of the National Defense Authorization
Act for Fiscal Year 1996 (10 U.S.C. 1073 note).
(8) Trust funds
The term "trust funds" means the Federal Hospital Insurance
Trust Fund established in section 1395i of this title and the
Federal Supplementary Medical Insurance Trust Fund established in
section 1395t of this title.
(b) Demonstration project
(1) In general
(A) Establishment
The administering Secretaries are authorized to establish a
demonstration project (under an agreement entered into by the
administering Secretaries) under which the Secretary shall
reimburse the Secretary of Defense, from the trust funds, for
medicare health care services furnished to certain medicare-
eligible military retirees or dependents in a military
treatment facility or by a designated provider.
(B) Agreement
The agreement entered into under subparagraph (A) shall
include at a minimum -
(i) a description of the benefits to be provided to the
participants of the demonstration project established under
this section;
(ii) a description of the eligibility rules for
participation in the demonstration project, including any
cost sharing requirements;
(iii) a description of how the demonstration project will
satisfy the requirements under this subchapter;
(iv) a description of the sites selected under paragraph
(2);
(v) a description of how reimbursement requirements under
subsection (i) of this section and maintenance of effort
requirements under subsection (j) of this section will be
implemented in the demonstration project;
(vi) a statement that the Secretary shall have access to
all data of the Department of Defense that the Secretary
determines is necessary to conduct independent estimates and
audits of the maintenance of effort requirement, the annual
reconciliation, and related matters required under the
demonstration project;
(vii) a description of any requirement that the Secretary
waives pursuant to subsection (d) of this section; and
(viii) a certification, provided after review by the
administering Secretaries, that any entity that is receiving
payments by reason of the demonstration project has
sufficient -
(I) resources and expertise to provide, consistent with
payments under subsection (i) of this section, the full
range of benefits required to be provided to beneficiaries
under the project; and
(II) information and billing systems in place to ensure
the accurate and timely submission of claims for benefits
and to ensure that providers of services, physicians, and
other health care professionals are reimbursed by the
entity in a timely and accurate manner.
(2) Number of sites
The project established under this section shall be conducted
in no more than 6 sites, designated jointly by the administering
Secretaries after review of all TRICARE regions.
(3) Restriction
No new military treatment facilities will be built or expanded
with funds from the demonstration project.
(4) Duration
The administering Secretaries shall conduct the demonstration
project during the 4-year period beginning on January 1, 1998,
except that the administering Secretaries may negotiate and
(subject to section 712(f) of the Floyd D. Spence National
Defense Authorization Act for Fiscal Year 2001) enter into a new
or revised agreement under paragraph (1)(A) to continue the
project after the end of such period. If the project is so
continued, the administering Secretaries may terminate the
agreement under which the program operates after providing notice
to Congress in accordance with subsection (k)(2)(B)(v) (!1) of
this section.
(5) Report
At least 60 days prior to the commencement of the demonstration
project, the administering Secretaries shall submit a copy of the
agreement entered into under paragraph (1) to the committees of
jurisdiction under this subchapter.
(c) Crediting of payments
A payment received by the Secretary of Defense under the
demonstration project shall be credited to the applicable
Department of Defense medical appropriation (and within that
appropriation). Any such payment received during a fiscal year for
services provided during a prior fiscal year may be obligated by
the Secretary of Defense during the fiscal year during which the
payment is received.
(d) Waiver of certain medicare requirements
(1) Authority
(A) In general
Except as provided under subparagraph (B), the demonstration
project shall meet all requirements of Medicare+Choice plans
under part C of this subchapter and regulations pertaining
thereto, and other requirements for receiving medicare
payments, except that the prohibition of payments to Federal
providers of services under sections 1395f(c) and 1395n(d) of
this title, and paragraphs (2) and (3) of section 1395y(a) of
this title shall not apply.
(B) Waiver
Except as provided in paragraph (2), the Secretary is
authorized to waive any requirement described under
subparagraph (A), or approve equivalent or alternative ways of
meeting such a requirement, but only if such waiver or approval
-
(i) reflects the unique status of the Department of Defense
as an agency of the Federal Government; and
(ii) is necessary to carry out the demonstration project.
(2) Beneficiary protections and other matters
The demonstration project shall comply with the requirements of
part C of this subchapter that relate to beneficiary protections
and other matters, including such requirements relating to the
following areas:
(A) Enrollment and disenrollment.
(B) Nondiscrimination.
(C) Information provided to beneficiaries.
(D) Cost-sharing limitations.
(E) Appeal and grievance procedures.
(F) Provider participation.
(G) Access to services.
(H) Quality assurance and external review.
(I) Advance directives.
(J) Other areas of beneficiary protections that the Secretary
determines are applicable to such project.
(e) Inspector General
Nothing in the agreement entered into under subsection (b) of
this section shall limit the Inspector General of the Department of
Health and Human Services from investigating any matters regarding
the expenditure of funds under this subchapter for the
demonstration project, including compliance with the provisions of
this subchapter and all other relevant laws.
(f) Voluntary participation
Participation of medicare-eligible military retirees or
dependents in the demonstration project shall be voluntary.
(g) TRICARE health care plans
(1) Modification of TRICARE contracts
In carrying out the demonstration project, the Secretary of
Defense is authorized to amend existing TRICARE contracts
(including contracts with designated providers) in order to
provide the medicare health care services to the medicare-
eligible military retirees and dependents enrolled in the
demonstration project consistent with part C of this subchapter.
(2) Health care benefits
The administering Secretaries shall prescribe the minimum
health care benefits to be provided under such a plan to medicare-
eligible military retirees or dependents enrolled in the plan.
Those benefits shall include at least all medicare health care
services covered under this subchapter.
(h) Additional plans
Notwithstanding any provisions of title 10, the administering
Secretaries may agree to include in the demonstration project any
of the Medicare+Choice plans described in section 1395w-21(a)(2)(A)
of this title, and such agreement may include an agreement between
the Secretary of Defense and the Medicare+Choice organization
offering such plan to provide medicare health care services to
medicare-eligible military retirees or dependents and for such
Secretary to receive payments from such organization for the
provision of such services.
(i) Payments based on regular medicare payment rates
(1) In general
Subject to the succeeding provisions of this subsection, the
Secretary shall reimburse the Secretary of Defense for services
provided under the demonstration project at a rate equal to 95
percent of the amount paid to a Medicare+Choice organization
under part C of this subchapter with respect to such an enrollee.
In cases in which a payment amount may not otherwise be readily
computed, the Secretary shall establish rules for computing
equivalent or comparable payment amounts.
(2) Exclusion of certain amounts
In computing the amount of payment under paragraph (1), the
following shall be excluded:
(A) Special payments
Any amount attributable to an adjustment under subparagraphs
(B) and (F) of section 1395ww(d)(5) of this title and
subsection (h) of such section.
(B) Percentage of capital payments
An amount determined by the administering Secretaries for
amounts attributable to payments for capital-related costs
under subsection (g) of such section.
(3) Periodic payments from medicare trust funds
Payments under this subsection shall be made -
(A) on a periodic basis consistent with the periodicity of
payments under this subchapter; and
(B) in appropriate part, as determined by the Secretary, from
the trust funds.
(4) Cap on amount
The aggregate amount to be reimbursed under this subsection
pursuant to the agreement entered into between the administering
Secretaries under subsection (b) of this section shall not exceed
a total of -
(A) $50,000,000 for calendar year 1998;
(B) $60,000,000 for calendar year 1999;
(C) $65,000,000 for calendar year 2000; and
(D) $70,000,000 for calendar year 2001.
(j) Maintenance of effort
(1) Monitoring effect of demonstration program on costs to
medicare program
(A) In general
The administering Secretaries, in consultation with the
Comptroller General, shall closely monitor the expenditures
made under the medicare program for medicare-eligible military
retirees or dependents during the period of the demonstration
project compared to the expenditures that would have been made
for such medicare-eligible military retirees or dependents
during that period if the demonstration project had not been
conducted. The agreement entered into by the administering
Secretaries under subsection (b) of this section shall require
any participating military treatment facility to maintain the
level of effort for space available care to medicare-eligible
military retirees or dependents.
(B) Annual report by the Comptroller General
Not later than December 31 of each year during which the
demonstration project is conducted, the Comptroller General
shall submit to the administering Secretaries and the
appropriate committees of Congress a report on the extent, if
any, to which the costs of the Secretary under the medicare
program under this subchapter increased during the preceding
fiscal year as a result of the demonstration project.
(2) Required response in case of increase in costs
(A) In general
If the administering Secretaries find, based on paragraph
(1), that the expenditures under the medicare program under
this subchapter increased (or are expected to increase) during
a fiscal year because of the demonstration project, the
administering Secretaries shall take such steps as may be
needed -
(i) to recoup for the medicare program the amount of such
increase in expenditures; and
(ii) to prevent any such increase in the future.
(B) Steps
Such steps -
(i) under subparagraph (A)(i) shall include payment of the
amount of such increased expenditures by the Secretary of
Defense from the current medical care appropriation of the
Department of Defense to the trust funds; and
(ii) under subparagraph (A)(ii) shall include suspending or
terminating the demonstration project (in whole or in part)
or lowering the amount of payment under subsection (i)(1) of
this section.
(k) Evaluation and reports
(1) Independent evaluation
The Comptroller General of the United States shall conduct an
evaluation of the demonstration project, and shall submit annual
reports on the demonstration project to the administering
Secretaries and to the committees of jurisdiction in the
Congress. The first report shall be submitted not later than 12
months after the date on which the demonstration project begins
operation, and the final report not later than 3 1/2 years after
that date. The evaluation and reports shall include an
assessment, based on the agreement entered into under subsection
(b) of this section, of the following:
(A) Any savings or costs to the medicare program under this
subchapter resulting from the demonstration project.
(B) The cost to the Department of Defense of providing care
to medicare-eligible military retirees and dependents under the
demonstration project.
(C) A description of the effects of the demonstration project
on military treatment facility readiness and training and the
probable effects of the project on overall Department of
Defense medical readiness and training.
(D) Any impact of the demonstration project on access to care
for active duty military personnel and their dependents.
(E) An analysis of how the demonstration project affects the
overall accessibility of the uniformed services treatment
system and the amount of space available for point-of-service
care, and a description of the unintended effects (if any) upon
the normal treatment priority system.
(F) Compliance by the Department of Defense with the
requirements under this subchapter.
(G) The number of medicare-eligible military retirees and
dependents opting to participate in the demonstration project
instead of receiving health benefits through another health
insurance plan (including benefits under this subchapter).
(H) A list of the health insurance plans and programs that
were the primary payers for medicare-eligible military retirees
and dependents during the year prior to their participation in
the demonstration project and the distribution of their
previous enrollment in such plans and programs.
(I) Any impact of the demonstration project on private health
care providers and beneficiaries under this subchapter that are
not enrolled in the demonstration project.
(J) An assessment of the access to care and quality of care
for medicare-eligible military retirees and dependents under
the demonstration project.
(K) An analysis of whether, and in what manner, easier access
to the uniformed services treatment system affects the number
of medicare-eligible military retirees and dependents receiving
medicare health care services.
(L) Any impact of the demonstration project on the access to
care for medicare-eligible military retirees and dependents who
did not enroll in the demonstration project and for other
individuals entitled to benefits under this subchapter.
(M) A description of the difficulties (if any) experienced by
the Department of Defense in managing the demonstration project
and TRICARE contracts.
(N) Any additional elements specified in the agreement
entered into under subsection (b) of this section.
(O) Any additional elements that the Comptroller General of
the United States determines is appropriate to assess regarding
the demonstration project.
(2) Repealed. Pub. L. 107-314, div. A, title VII, Sec. 713, Dec.
2, 2002, 116 Stat. 2589