H.R. 3200/Division B/Title I/Subtitle D/Part 2

PART 2 — BENEFICIARY PROTECTIONS AND ANTI-FRAUD

Sec. 1171. Limitation on Cost-Sharing for Individual Health Services.

(a) In General.—

Section 1852(a)(1) of the Social Security Act (42 U.S.C. 1395w–22(a)(1)) is amended—

(1) in subparagraph (A), by inserting before the period at the end the following: ``with cost-sharing that is no greater (and may be less) than the cost-sharing that would otherwise be imposed under such program option´´;

(2) in subparagraph (B)(i), by striking ``or an actuarially equivalent level of cost-sharing as determined in this part´´; and

(3) by amending clause (ii) of subparagraph (B) to read as follows:

``(ii) Permitting use of flat copayment or per diem rate.—Nothing in clause (i) shall be construed as prohibiting a Medicare Advantage plan from using a flat copayment or per diem rate, in lieu of the cost-sharing that would be imposed under part A or B, so long as the amount of the cost-sharing imposed does not exceed the amount of the cost-sharing that would be imposed under the respective part if the individual were not enrolled in a plan under this part.´´.

(b) Limitation for Dual Eligibles and Qualified Medicare Beneficiaries.—

Section 1852(a) of such Act is amended by adding at the end the following new paragraph:

``(7) Limitation on cost-sharing for dual eligibles and qualified medicare beneficiaries.—In the case of a individual who is a full-benefit dual eligible individual (as defined in section 1935(c)(6)) or a qualified medicare beneficiary (as defined in section 1905(p)(1)) who is enrolled in a Medicare Advantage plan, the plan may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted with respect to the individual under this title and title XIX if the individual were not enrolled with such plan.´´.

(c) Effective Dates.—

(1) The amendments made by subsection (a) shall apply to plan years beginning on or after January 1, 2011.

(2) The amendments made by subsection (b) shall apply to plan years beginning on or after January 1, 2011.

Sec. 1172. Continuous Open Enrollment for Enrollees in Plans with Enrollment Suspension.

Section 1851(e)(4) of the Social Security Act (42 U.S.C. 1395w(e)(4)) is amended—

(1) in subparagraph (C), by striking at the end ``or´´;

(2) in subparagraph (D)—

(A) by inserting ``, taking into account the health or well-being of the individual´´ before the period; and

(B) by redesignating such subparagraph as subparagraph (E); and

(3) by inserting after subparagraph (C) the following new subparagraph:

``(D) the individual is enrolled in an MA plan and enrollment in the plan is suspended under paragraph (2)(B) or (3)(C) of section 1857(g) because of a failure of the plan to meet applicable requirements; or´´.

Sec. 1173. Information for Beneficiaries on MA Plan Administrative Costs.

(a) Disclosure of Medical Loss Ratios and Other Expense Data.—

Section 1851 of the Social Security Act (42 U.S.C. 1395w–21), as previously amended by this subtitle, is amended by adding at the end the following new subsection:

``(p) Publication of medical loss ratios and other cost-related information.—

``(1) In general.—The Secretary shall publish, not later than November 1 of each year (beginning with 2011), for each MA plan contract, the medical loss ratio of the plan in the previous year.

``(2) Submission of data.—

``(A) In general.—Each MA organization shall submit to the Secretary, in a form and manner specified by the Secretary, data necessary for the Secretary to publish the medical loss ratio on a timely basis.

``(B) Data for 2010 and 2011.—The data submitted under subparagraph (A) for 2010 and for 2011 shall be consistent in content with the data reported as part of the MA plan bid in June 2009 for 2010.

``(C) Use of standardized elements and definitions.—The data to be submitted under subparagraph (A) relating to medical loss ratio for a year, beginning with 2012, shall be submitted based on the standardized elements and definitions developed under paragraph (3).

``(3) Development of data reporting standards.—

``(A) In general.—The Secretary shall develop and implement standardized data elements and definitions for reporting under this subsection, for contract years beginning with 2012, of data necessary for the calculation of the medical loss ratio for MA plans. Not later than December 31, 2010, the Secretary shall publish a report describing the elements and definitions so developed.

``(B) Consultation.—The Secretary shall consult with the Health Choices Commissioner, representatives of MA organizations, experts on health plan accounting systems, and representatives of the National Association of Insurance Commissioners, in the development of such data elements and definitions.

``(4) Medical loss ratio to be defined.—For purposes of this part, the term ‘medical loss ratio’ has the meaning given such term by the Secretary, taking into account the meaning given such term by the Health Choices Commissioner under section 116 of the America’s Affordable Health Choices Act of 2009.´´.

(b) Minimum Medical Loss Ratio.—

Section 1857(e) of the Social Security Act (42 U.S.C. 1395w–27(e)) is amended by adding at the end the following new paragraph:

``(4) Requirement for minimum medical loss ratio.—If the Secretary determines for a contract year (beginning with 2014) that an MA plan has failed to have a medical loss ratio (as defined in section 1851(p)(4)) of at least .85—

``(A) the Secretary shall require the Medicare Advantage organization offering the plan to give enrollees a rebate (in the second succeeding contract year) of premiums under this part (or part B or part D, if applicable) by such amount as would provide for a benefits ratio of at least .85;

``(B) for 3 consecutive contract years, the Secretary shall not permit the enrollment of new enrollees under the plan for coverage during the second succeeding contract year; and

``(C) the Secretary shall terminate the plan contract if the plan fails to have such a medical loss ratio for 5 consecutive contract years.´´.

Sec. 1174. Strengthening Audit Authority.

(a) For PART C Payments Risk Adjustment.—

Section 1857(d)(1) of the Social Security Act (42 U.S.C. 1395w–27(d)(1)) is amended by inserting after ``section 1858(c))´´ the following: ``, and data submitted with respect to risk adjustment under section 1853(a)(3)´´.

(b) Enforcement of Audits and Deficiencies.—

(1) In General.—

Section 1857(e) of such Act, as amended by section 1173, is amended by adding at the end the following new paragraph:

``(5) Enforcement of audits and deficiencies.—

``(A) Information in contract.—The Secretary shall require that each contract with an MA organization under this section shall include terms that inform the organization of the provisions in subsection (d).

``(B) Enforcement authority.—The Secretary is authorized, in connection with conducting audits and other activities under subsection (d), to take such actions, including pursuit of financial recoveries, necessary to address deficiencies identified in such audits or other activities.´´.

(2) Application Under PART D.—

For provision applying the amendment made by paragraph (1) to prescription drug plans under part D, see section 1860D–12(b)(3)(D) of the Social Security Act.

(c) Effective Date.—

The amendments made by this section shall take effect on the date of the enactment of this Act and shall apply to audits and activities conducted for contract years beginning on or after January 1, 2011.

Sec. 1175. Authority to Deny Plan Bids.

(a) In General.—

Section 1854(a)(5) of the Social Security Act (42 U.S.C. 1395w–24(a)(5)) is amended by adding at the end the following new subparagraph:

``(C) Rejection of bids.—Nothing in this section shall be construed as requiring the Secretary to accept any or every bid by an MA organization under this subsection.´´.

(b) Application Under PART D.—

Section 1860D–11(d) of such Act (42 U.S.C. 1395w–111(d)) is amended by adding at the end the following new paragraph:

``(3) Rejection of bids.—Paragraph (5)(C) of section 1854(a) shall apply with respect to bids under this section in the same manner as it applies to bids by an MA organization under such section.´´.

(c) Effective Date.—

The amendments made by this section shall apply to bids for contract years beginning on or after January 1, 2011.