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42 U.S. Code § 1395w-28. Definitions; miscellaneous provisions
(a) Definitions relating to Medicare+Choice organizationsIn this part—
(1) Medicare+Choice organization
The term “Medicare+Choice organization” means a public or private entity that is certified under section 1395w–26 of this title as meeting the requirements and standards of this part for such an organization.
(2) Provider-sponsored organization
The term “provider-sponsored organization” is defined in section 1395w–25(d)(1) of this title.
(b) Definitions relating to Medicare+Choice plans
(1) Medicare+Choice plan
The term “Medicare+Choice plan” means health benefits coverage offered under a policy, contract, or plan by a Medicare+Choice organization pursuant to and in accordance with a contract under section 1395w–27 of this title.
(2) Medicare+Choice private fee-for-service planThe term “Medicare+Choice private fee-for-service plan” means a Medicare+Choice plan that—
(A)
reimburses hospitals, physicians, and other providers at a rate determined by the plan on a fee-for-service basis without placing the provider at financial risk;
(B)
does not vary such rates for such a provider based on utilization relating to such provider; and
(C)
does not restrict the selection of providers among those who are lawfully authorized to provide the covered services and agree to accept the terms and conditions of payment established by the plan.
Nothing in subparagraph (B) shall be construed to preclude a plan from varying rates for such a provider based on the specialty of the provider, the location of the provider, or other factors related to such provider that are not related to utilization, or to preclude a plan from increasing rates for such a provider based on increased utilization of specified preventive or screening services.
(3) MSA plan
(A) In generalThe term “MSA plan” means a Medicare+ÐChoice plan that—
(i)
provides reimbursement for at least the items and services described in section 1395w–22(a)(1) of this title in a year but only after the enrollee incurs countable expenses (as specified under the plan) equal to the amount of an annual deductible (described in subparagraph (B));
(ii)
counts as such expenses (for purposes of such deductible) at least all amounts that would have been payable under parts A and B, and that would have been payable by the enrollee as deductibles, coinsurance, or copayments, if the enrollee had elected to receive benefits through the provisions of such parts; and
(iii) provides, after such deductible is met for a year and for all subsequent expenses for items and services referred to in clause (i) in the year, for a level of reimbursement that is not less than—
(I)
100 percent of such expenses, or
(II)
100 percent of the amounts that would have been paid (without regard to any deductibles or coinsurance) under parts A and B with respect to such expenses,
whichever is less.
(B) DeductibleThe amount of annual deductible under an MSA plan—
(i)
for contract year 1999 shall be not more than $6,000; and
(ii)
for a subsequent contract year shall be not more than the maximum amount of such deductible for the previous contract year under this subparagraph increased by the national per capita Medicare+Choice growth percentage under section 1395w–23(c)(6) of this title for the year.
If the amount of the deductible under clause (ii) is not a multiple of $50, the amount shall be rounded to the nearest multiple of $50.
(4) MA regional planThe term “MA regional plan” means an MA plan described in section 1395w–21(a)(2)(A)(i) of this title—
(A)
that has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan;
(B)
that provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and
(C)
the service area of which is one or more entire MA regions.
(5) MA local plan
The term “MA local plan” means an MA plan that is not an MA regional plan.
(6) Specialized MA plans for special needs individuals
(A) In general
The term “specialized MA plan for special needs individuals” means an MA plan that exclusively serves special needs individuals (as defined in subparagraph (B)) and that, as of January 1, 2010, meets the applicable requirements of paragraph (2), (3), or (4) of subsection (f), as the case may be.
(B) Special needs individualThe term “special needs individual” means an MA eligible individual who—
(i)
is institutionalized (as defined by the Secretary);
(ii)
is entitled to medical assistance under a State plan under subchapter XIX; or
(iii) meets such requirements as the Secretary may determine would benefit from enrollment in such a specialized MA plan described in subparagraph (A) for individuals with severe or disabling chronic conditions who—
(I)
before January 1, 2022, have one or more comorbid and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care; and
(II)
on or after January 1, 2022, have one or more comorbid and medically complex chronic conditions that is life threatening or significantly limits [1] overall health or function, have a high risk of hospitalization or other adverse health outcomes, and require intensive care coordination and that is listed under subsection (f)(9)(A).
The Secretary may apply rules similar to the rules of section 1395eee(c)(4) of this title for continued eligibility of special needs individuals.