A bill to provide for an intra-HMO competition demonstration project.

Summary

Directs the Secretary of Health and Human Services to provide for Medicare (title XVIII of the Social Security Act) demonstration projects in at least four States, under which: (1) the Secretary would contract with one or more health maintenance organizations or competitive medical plans (organizations) to perform the functions both of intermediaries under part A (Hospital Insurance) of title XVIII and carriers under part B (Supplementary Medical Insurance) with respect to benefits furnished in a State; (2) if the Secretary contracts with one organization in an area, the Secretary must permit any other organization in the area to enter into such a contract; (3) individuals residing in the State covered by the project and entitled or enrolled under part A or B of title XVIII would be required to enroll with at least one participating organization, but may elect to receive any covered service through any qualified Medicare provider; (4) an organization may offer additional benefits, at no additional cost; (5) an organization will not charge copayments or deductibles if a beneficiary is enrolled with and receives benefits directly from the organization; (6) each organization would receive payment at an annual per capita rate equal to 95 percent of the adjusted per capita cost; and (7) each organization shall have the right of final claim review for necessity and appropriateness of items and services furnished. Directs the Secretary to submit to the Congress a protocol report concerning such demonstration projects and annual reports.

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1 official file

• Introduced in House

  summary · EN · 30 April 1985

  Open at official source

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