
From the U.S. Code Online via GPO Access
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[Laws in effect as of January 23, 2000]
[Document affected by Public Law 106-554 Section 1(a)(6)[612(a)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[614(a)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[612(b)]]
[Document affected by Public Law 106-554 Section 1(a)(6)[614(b)]]
[CITE: 42USC1395w-26]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
                     Part C--Medicare+Choice Program
 
Sec. 1395w-26. Establishment of standards


(a) Establishment of solvency standards for provider-sponsored 
        organizations

                          (1) Establishment

        (A) In general

            The Secretary shall establish, on an expedited basis and 
        using a negotiated rulemaking process under subchapter III of 
        chapter 5 of title 5, standards described in section 1395w-
        25(c)(1) of this title (relating to the financial solvency and 
        capital adequacy of the organization) that entities must meet to 
        qualify as provider-sponsored organizations under this part.

        (B) Factors to consider for solvency standards

            In establishing solvency standards under subparagraph (A) 
        for provider-sponsored organizations, the Secretary shall 
        consult with interested parties and shall take into account--
                (i) the delivery system assets of such an organization 
            and ability of such an organization to provide services 
            directly to enrollees through affiliated providers,
                (ii) alternative means of protecting against insolvency, 
            including reinsurance, unrestricted surplus, letters of 
            credit, guarantees, organizational insurance coverage, 
            partnerships with other licensed entities, and valuation 
            attributable to the ability of such an organization to meet 
            its service obligations through direct delivery of care, and
                (iii) any standards developed by the National 
            Association of Insurance Commissioners specifically for 
            risk-based health care delivery organizations.

        (C) Enrollee protection against insolvency

            Such standards shall include provisions to prevent enrollees 
        from being held liable to any person or entity for the Medicare+
        Choice organization's debts in the event of the organization's 
        insolvency.

                      (2) Publication of notice

        In carrying out the rulemaking process under this subsection, 
    the Secretary, after consultation with the National Association of 
    Insurance Commissioners, the American Academy of Actuaries, 
    organizations representative of medicare beneficiaries, and other 
    interested parties, shall publish the notice provided for under 
    section 564(a) of title 5 by not later than 45 days after August 5, 
    1997.

               (3) Target date for publication of rule

        As part of the notice under paragraph (2), and for purposes of 
    this subsection, the ``target date for publication'' (referred to in 
    section 564(a)(5) of such title) shall be April 1, 1998.

          (4) Abbreviated period for submission of comments

        In applying section 564(c) of such title under this subsection, 
    ``15 days'' shall be substituted for ``30 days''.

       (5) Appointment of negotiated rulemaking committee and 
                                 facilitator

        The Secretary shall provide for--
            (A) the appointment of a negotiated rulemaking committee 
        under section 565(a) of such title by not later than 30 days 
        after the end of the comment period provided for under section 
        564(c) of such title (as shortened under paragraph (4)), and
            (B) the nomination of a facilitator under section 566(c) of 
        such title by not later than 10 days after the date of 
        appointment of the committee.

                  (6) Preliminary committee report

        The negotiated rulemaking committee appointed under paragraph 
    (5) shall report to the Secretary, by not later than January 1, 
    1998, regarding the committee's progress on achieving a consensus 
    with regard to the rulemaking proceeding and whether such consensus 
    is likely to occur before 1 month before the target date for 
    publication of the rule. If the committee reports that the committee 
    has failed to make significant progress towards such consensus or is 
    unlikely to reach such consensus by the target date, the Secretary 
    may terminate such process and provide for the publication of a rule 
    under this subsection through such other methods as the Secretary 
    may provide.

                     (7) Final committee report

        If the committee is not terminated under paragraph (6), the 
    rulemaking committee shall submit a report containing a proposed 
    rule by not later than 1 month before the target date of 
    publication.

                      (8) Interim, final effect

        The Secretary shall publish a rule under this subsection in the 
    Federal Register by not later than the target date of publication. 
    Such rule shall be effective and final immediately on an interim 
    basis, but is subject to change and revision after public notice and 
    opportunity for a period (of not less than 60 days) for public 
    comment. In connection with such rule, the Secretary shall specify 
    the process for the timely review and approval of applications of 
    entities to be certified as provider-sponsored organizations 
    pursuant to such rules and consistent with this subsection.

            (9) Publication of rule after public comment

        The Secretary shall provide for consideration of such comments 
    and republication of such rule by not later than 1 year after the 
    target date of publication.

(b) Establishment of other standards

                           (1) In general

        The Secretary shall establish by regulation other standards (not 
    described in subsection (a) of this section) for Medicare+Choice 
    organizations and plans consistent with, and to carry out, this 
    part. The Secretary shall publish such regulations by June 1, 1998. 
    In order to carry out this requirement in a timely manner, the 
    Secretary may promulgate regulations that take effect on an interim 
    basis, after notice and pending opportunity for public comment.

                    (2) Use of current standards

        Consistent with the requirements of this part, standards 
    established under this subsection shall be based on standards 
    established under section 1395mm of this title to carry out 
    analogous provisions of such section.

                     (3) Relation to State laws

        (A) In general

            The standards established under this subsection shall 
        supersede any State law or regulation (including standards 
        described in subparagraph (B)) with respect to Medicare+
        Choice plans which are offered by Medicare+
        Choice organizations under this part to the extent such law or 
        regulation is inconsistent with such standards.

        (B) Standards specifically superseded

            State standards relating to the following are superseded 
        under this paragraph:
                (i) Benefit requirements.
                (ii) Requirements relating to inclusion or treatment of 
            providers.
                (iii) Coverage determinations (including related appeals 
            and grievance processes).

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1856, as added Pub. L. 105-
33, title IV, Sec. 4001, Aug. 5, 1997, 111 Stat. 317.)

                  Section Referred to in Other Sections

    This section is referred to in sections 1395w-21, 1395w-22, 1395w-
25, 1395w-28, 1395mm of this title.
