Provider-Sponsored Organization Act of 1997

Summary

Provider-Sponsored Organization Act of 1997 - Amends title XVIII (Medicare) of the Social Security Act (SSA) to give Medicare beneficiaries the option of receiving Medicare coverage through enrollment with provider-sponsored organizations (PSOs) organized and licensed under State law, and certified as meeting certain Federal standards. Requires a PSO to be a qualified health maintenance organization (HMO) and meet other specified criteria. (Sec. 3) Authorizes the Secretary to pay all Medicare health plans on a partial risk basis. (Sec. 4) Requires a PSO to: (1) deliver a spectrum of health care services (including basic hospital and physicians services) to enrolled purchasers; and (2) provide a substantial proportion of the health care items and services under its Medicare contract through the provider or affiliated group of providers composing the organization. Provides for direct Federal Medicare certification as a qualified PSO through calendar 2001. Authorizes State licensure of PSOs after January 1, 2002, only if: (1) State financial solvency and capital adequacy standards are identical with Federal standards; and (2) State licensure standards are substantially equivalent to Federal standards. Allows a PSO seeking to operate under a full-risk contract or a partial risk contract to apply to the Secretary of Health and Human Services for waiver of State licensure if: (1) the State has failed to act on the PSO's State application within a certain period of time; or (2) the State has denied the PSO's application, but the State's licensing standards or review process impose unreasonable barriers to market entry. Declares that a fiscally sound PSO meets Medicare financial solvency requirements. Prescribes general requirements for a PSO's ongoing quality assurance program (including case-by-case utilization review). Treats such requirements as met if the PSO is accredited by a private organization under a process approved by the Secretary. (Sec. 5) Treats Medicare-eligible organizations, including PSOs, as meeting the "50-50" enrollment composition rule (which requires that a health plan's Medicare and Medicaid enrollees cannot exceed 50 percent of its total enrollment) if they demonstrate: (1) their capability of providing coordinated care in accordance with the quality assurance standards established by this Act; and (2) their experience providing coordinated care to enrollees of a health plan or State Medicaid plan. Reduces enrollment size requirements for eligible organizations under Medicare. (Sec. 6) Permits computation of the adjusted community rate of payment for services for a qualified PSO using data in the general commercial marketplace or (during a transition period) based on costs incurred by the PSO in providing a product. (Sec. 7) Sets forth physician-participation procedure requirements. (Sec. 8) Directs the Secretary to: (1) issue regulations regarding qualified PSO standards; and (2) establish a process for certification of qualified PSOs (including a discretionary application fee). (Sec. 9) Directs the Secretary to provide for demonstration projects in at least ten States that permit Medicaid programs to be treated as Medicare-eligible organizations for individuals eligible to enroll with a Medicare organization and also eligible for Medicaid, for the purpose of demonstrating the delivery of primary, acute, and long-term care through an integrated delivery network that emphasizes noninstitutional care. (Sec. 10) Requires the Secretary to report to the Congress on Medicare partial-risk contracts.

This text is taken from the official record. PoliticalRepo does not editorialize.

Timeline

No timeline events have been ingested for this record yet.

Votes

No vote records are attached yet.

Versions

No version snapshots stored. Document URLs remain at the source.

Documents

3 official files

• Introduced in Senate (text)

  Introduced in Senate · EN · 21 January 1997

  ViewDownloadOpen at official source

• Introduced in Senate (PDF)

  Introduced in Senate · EN · 21 January 1997

  ViewDownloadOpen at official source

• Introduced in Senate

  summary · EN · 21 January 1997

  Open at official source

Sponsors

No sponsors or actors listed by the source.

Related records

No cross-record relationships stored yet.