Medicare Preferred Provider Arrangement Act

Summary

Medicare Preferred Provider Arrangement Act - Amends part B (Supplementary Medical Insurance) of title XVIII (Medicare) of the Social Security Act to authorize the Secretary of Health and Human Services to enter into a contract with any insurer or other third party payor under which payments shall be made to such insurer or payor on behalf of individuals enrolled under part B who participate in a preferred provider arrangement, established by such insurer or payor, which meets the requirements of this Act. Provides that the amount of the payment to the insurer or other third party payor per capita for each individual enrolled under part B who participates in the preferred provider arrangement (participating part B beneficiaries) shall be the same payment amount as determined for payment to a health maintenance organization for individuals who are enrolled under part B but are entitled to benefits under part A (Hospital Insurance) of title XVIII, and are enrolled with health maintenance organizations or competitive medical plans having risk-sharing contracts. Requires payment to be made in the same manner as under such risk-sharing contracts. Provides that payments under this Act shall be instead of any payments which would otherwise be payable under part B for services furnished through the preferred provider arrangement to its participating part B beneficiaries, and no other payments shall be made under part B to or on behalf of participating part B beneficiaries for services which are available to them from or through the arrangement. Requires a preferred provider arrangement, in order to meet the requirements of this Act, to meet the following requirements: (1) the arrangement must provide at a minimum for physicians' services and for laboratory, x-ray, emergency, and preventive services to be available 24 hours a day and seven days a week; (2) provisions must be made for payment to physicians other than participating physicians if the services furnished were necessary and it was not reasonable under the circumstances to obtain the services through a participating physician; (3) the portion of the premium rate charged by the arrangement, and the actuarial value of its deductibles, coinsurance, and copayments charged, for services covered under this part provided to its participating part B beneficiares may not exceed the actuarial value of the coinsurance and deductibles which would be applicable on the average to its participating part B beneficiaries if they were not participating in any preferred provider arrangement; (4) subject to open enrollment requirements, the arrangement must be open to any individual enrolled in part B, other than an individual with end stage renal disease; (5) the arrangement must provide for an open enrollment period of at least 30 days duration annually; (6) the insurer or other third party payor must provide assurances that adequate provision against the risk of insolvency has made; and (7) the insurer or other third party payor must provide meaningful procedures for hearings and resolving grievances between the insurer or payor, including any participating provider, and its participating part B beneficiaries. Provides that contracts under this Act shall be for a term of at least one year and may be automatically renewable in the absence of notice by either party of intention to terminate at the end of a term, except that the Secretary may terminate a contract at any time (after notice and opportunity for a hearing) if the insurer or other third party payor fails to meet the requirements of this Act or the contract.

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1 official file

• Introduced in Senate

  summary · EN · 29 March 1984

  Open at official source

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