Medicare Private Health Plan Capitation Improvement Act of 1987

Summary

Medicare Private Health Plan Capitation Improvement Act of 1987 - Establishes a Task Force on Medicare Capitation responsible for reviewing, assessing, and reporting to the Congress by 1991 on a wide range of issues involving Medicare (title XVIII of the Social Security Act) capitation payments to health maintenance organizations (HMOs). Terminates such Task Force on January 2, 1991. Authorizes appropriations for such Task Force for FY 1988 through 1991. Amends the Medicare program to guarantee that for calendar years 1988 through 1991, HMOs will receive payments for their enrollees which will be no less than 80 percent of the median adjusted average per capita cost (AAPCC) received for similar Medicare beneficiaries residing in Metropolitan Statistical Areas (MSAs). Directs the Secretary of Health and Human Services to issue annually to HMOs: (1) a summary of the calculations and a description of the assumptions made by the Secretary in computing the United States per capita incurred cost (USPCC) and the AAPCC; (2) preliminary estimates of the USPCC and the AAPCC for the next year; and (3) by April 1, a narrative explanation of differences between the preliminary estimate of the USPCC issued before the previous September 7, and the USPCC projection issued before the following September 7 and the actual USPCC. Gives HMOs notice of, and 30 days to comment on, any proposed changes in the method of computing the USPCC or AAPCC. Requires the Secretary to use data from the six months preceding establishment of the AAPCC as the basis for determining the AAPCC. Requires the Secretary to establish a separate class of HMO members composed of individuals who reach age 65 from 1988 through 1991, are entitled to Medicare benefits, and received disability benefits under title II (Old Age, Survivors and Disability Insurance) of the Act for purposes of determining the per capita rate of payments to HMOs. Prohibits HMO premiums for services in addition to Medicare services from being increased more than once in a contract year. Permits HMOs to have different premiums or charges for each MSA or group of two or more counties not contiguous to MSAs, in which members reside. Directs the Secretary to waive or modify the rule that at least 50 percent of HMO enrollees not be entitled to Medicare or Medicaid if quality standards are met, certain fiscal soundness requirements are exceeded, and the HMO has operated successfully for at least five years. Provides that HMOs which are affiliates of multistate or multicontract entities shall not be held to the 50 percent rule if the rule would be satisfied if applied to the enrolled membership of all organizations affiliated with such entities. Requires the General Accounting Office to conduct an audit of Medicare claims to assess, and report to the Congress by 1989 regarding, the impact of beneficiary location and retroactive adjustments on the attribution of claims.

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1 official file

• Introduced in Senate

  summary · EN · 30 September 1987

  Open at official source

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