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42 U.S. Code § 1395w-24. Premiums and bid amounts
(a) Submission of proposed premiums, bid amounts, and related information
(1) In general
(A) Initial submissionNot later than the second Monday in September of 2002, 2003, and 2004 (or the first Monday in June of each subsequent year), each MA organization shall submit to the Secretary, in a form and manner specified by the Secretary and for each MA plan for the service area (or segment of such an area if permitted under subsection (h)) in which it intends to be offered in the following year the following:
(i)
The information described in paragraph (2), (3), (4), or (6)(A) for the type of plan and year involved.
(ii)
The plan type for each plan.
(iii)
The enrollment capacity (if any) in relation to the plan and area.
(B) Beneficiary rebate informationIn the case of a plan required to provide a monthly rebate under subsection (b)(1)(C) for a year, the MA organization offering the plan shall submit to the Secretary, in such form and manner and at such time as the Secretary specifies, information on—
(i)
the manner in which such rebate will be provided under clause (ii) of such subsection; and
(ii)
the MA monthly prescription drug beneficiary premium (if any) and the MA monthly supplemental beneficiary premium (if any).
(C) Paperwork reduction for offering of MA regional plans nationally or in multi-region areas
The Secretary shall establish requirements for information submission under this subsection in a manner that promotes the offering of MA regional plans in more than one region (including all regions) through the filing of consolidated information.
(2) Information required for coordinated care plans before 2006For a Medicare+Choice plan described in section 1395w–21(a)(2)(A) of this title for a year before 2006, the information described in this paragraph is as follows:
(A) Basic (and additional) benefitsFor benefits described in section 1395w–22(a)(1)(A) of this title—
(i)
the adjusted community rate (as defined in subsection (f)(3));
(ii)
the Medicare+Choice monthly basic beneficiary premium (as defined in subsection (b)(2)(A));
(iii)
a description of deductibles, coinsurance, and copayments applicable under the plan and the actuarial value of such deductibles, coinsurance, and copayments, described in subsection (e)(1)(A); and
(iv)
if required under subsection (f)(1), a description of the additional benefits to be provided pursuant to such subsection and the value determined for such proposed benefits under such subsection.
(B) Supplemental benefitsFor benefits described in section 1395w–22(a)(3) of this title—
(i)
the adjusted community rate (as defined in subsection (f)(3));
(ii)
the Medicare+Choice monthly supplemental beneficiary premium (as defined in subsection (b)(2)(B)); and
(iii)
a description of deductibles, coinsurance, and copayments applicable under the plan and the actuarial value of such deductibles, coinsurance, and copayments, described in subsection (e)(2).
(3) Requirements for MSA plansFor an MSA plan for any year, the information described in this paragraph is as follows:
(A) Basic (and additional) benefits
For benefits described in section 1395w–22(a)(1)(A) of this title, the amount of the Medicare+Choice monthly MSA premium.
(B) Supplemental benefits
For benefits described in section 1395w–22(a)(3) of this title, the amount of the Medicare+Choice monthly supplementary beneficiary premium.
(4) Requirements for private fee-for-service plans before 2006For a Medicare+Choice plan described in section 1395w–21(a)(2)(C) of this title for benefits described in section 1395w–22(a)(1)(A) of this title for a year before 2006, the information described in this paragraph is as follows:
(A) Basic (and additional) benefitsFor benefits described in section 1395w–22(a)(1)(A) of this title—
(i)
the adjusted community rate (as defined in subsection (f)(3));
(ii)
the amount of the Medicare+Choice monthly basic beneficiary premium;
(iii)
a description of the deductibles, coinsurance, and copayments applicable under the plan, and the actuarial value of such deductibles, coinsurance, and copayments, as described in subsection (e)(4)(A); and
(iv)
if required under subsection (f)(1), a description of the additional benefits to be provided pursuant to such subsection and the value determined for such proposed benefits under such subsection.
(B) Supplemental benefits
For benefits described in section 1395w–22(a)(3) of this title, the amount of the Medicare+Choice monthly supplemental beneficiary premium (as defined in subsection (b)(2)(B)).
(5) Review
(A) In general
Subject to subparagraph (B), the Secretary shall review the adjusted community rates, the amounts of the basic and supplemental premiums, and values filed under paragraphs (2) and (4) of this subsection and shall approve or disapprove such rates, amounts, and values so submitted. The Chief Actuary of the Centers for Medicare & Medicaid Services shall review the actuarial assumptions and data used by the Medicare+Choice organization with respect to such rates, amounts, and values so submitted to determine the appropriateness of such assumptions and data.
(B) Exception
The Secretary shall not review, approve, or disapprove the amounts submitted under paragraph (3) or, in the case of an MA private fee-for-service plan, subparagraphs (A)(ii) and (B) of paragraph (4).
(C) Rejection of bids
(i) In general
Nothing in this section shall be construed as requiring the Secretary to accept any or every bid submitted by an MA organization under this subsection.
(ii) Authority to deny bids that propose significant increases in cost sharing or decreases in benefits
The Secretary may deny a bid submitted by an MA organization for an MA plan if it proposes significant increases in cost sharing or decreases in benefits offered under the plan.
(6) Submission of bid amounts by MA organizations beginning in 2006
(A) Information to be submittedFor an MA plan (other than an MSA plan) for a plan year beginning on or after January 1, 2006, the information described in this subparagraph is as follows:
(i)
The monthly aggregate bid amount for the provision of all items and services under the plan, which amount shall be based on average revenue requirements (as used for purposes of section 300e–1(8) of this title) in the payment area for an enrollee with a national average risk profile for the factors described in section 1395w–23(a)(1)(C) of this title (as specified by the Secretary).
(ii) The proportions of such bid amount that are attributable to—
(I)
the provision of benefits under the original medicare fee-for-service program option (as defined in section 1395w–22(a)(1)(B) of this title), including, for plan year 2020 and subsequent plan years, the provision of additional telehealth benefits as described in section 1395w–22(m) of this title;
(II)
the provision of basic prescription drug coverage; and
(III)
the provision of supplemental health care benefits.
(iii)
The actuarial basis for determining the amount under clause (i) and the proportions described in clause (ii) and such additional information as the Secretary may require to verify such actuarial bases and the projected number of enrollees in each MA local area.
(iv)
A description of deductibles, coinsurance, and copayments applicable under the plan and the actuarial value of such deductibles, coinsurance, and copayments, described in subsection (e)(4)(A).
(v)
With respect to qualified prescription drug coverage, the information required under section 1395w–104 of this title, as incorporated under section 1395w–111(b)(2) of this title, with respect to such coverage.
In the case of a specialized MA plan for special needs individuals, the information described in this subparagraph is such information as the Secretary shall specify.
(B) Acceptance and negotiation of bid amounts
(i) Authority
Subject to clauses (iii) and (iv), the Secretary has the authority to negotiate regarding monthly bid amounts submitted under subparagraph (A) (and the proportions described in subparagraph (A)(ii)), including supplemental benefits provided under subsection (b)(1)(C)(ii)(I) and in exercising such authority the Secretary shall have authority similar to the authority of the Director of the Office of Personnel Management with respect to health benefits plans under chapter 89 of title 5.
(ii) Application of FEHBP standard
Subject to clause (iv), the Secretary may only accept such a bid amount or proportion if the Secretary determines that such amount and proportions are supported by the actuarial bases provided under subparagraph (A) and reasonably and equitably reflects the revenue requirements (as used for purposes of section 300e–1(8) of this title) of benefits provided under that plan.
(iii) Noninterference
In order to promote competition under this part and part D and in carrying out such parts, the Secretary may not require any MA organization to contract with a particular hospital, physician, or other entity or individual to furnish items and services under this subchapter or require a particular price structure for payment under such a contract to the extent consistent with the Secretary’s authority under this part.
(iv) Exception
In the case of a plan described in section 1395w–21(a)(2)(C) of this title, the provisions of clauses (i) and (ii) shall not apply and the provisions of paragraph (5)(B), prohibiting the review, approval, or disapproval of amounts described in such paragraph, shall apply to the negotiation and rejection of the monthly bid amounts and the proportions referred to in subparagraph (A).