
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1395w-28]

 
                 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-28. Definitions; miscellaneous provisions


(a) Definitions relating to Medicare+Choice organizations

    In 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 plan

        The 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.

                            (3) MSA plan

        (A) In general

            The term ``MSA plan'' means a Medicare+
        Choice 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 of this subchapter, 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 of this subchapter with respect to 
                such expenses,

          whichever is less.

        (B) Deductible

            The 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.

(c) Other references to other terms

               (1) Medicare+Choice eligible individual

        The term ``Medicare+Choice eligible individual'' is defined in 
    section 1395w-21(a)(3) of this title.

                  (2) Medicare+Choice payment area

        The term ``Medicare+Choice payment area'' is defined in section 
    1395w-23(d) of this title.

      (3) National per capita Medicare+Choice growth percentage

        The ``national per capita Medicare+Choice growth percentage'' is 
    defined in section 1395w-23(c)(6) of this title.

       (4) Medicare+Choice monthly basic beneficiary premium; 
              Medicare+Choice monthly supplemental beneficiary 
                                   premium

        The terms ``Medicare+Choice monthly basic beneficiary premium'' 
    and ``Medicare+Choice monthly supplemental beneficiary premium'' are 
    defined in section 1395w-24(a)(2) of this title.

(d) Coordinated acute and long-term care benefits under Medicare+Choice 
        plan

    Nothing in this part shall be construed as preventing a State from 
coordinating benefits under a medicaid plan under subchapter XIX of this 
chapter with those provided under a Medicare+Choice plan in a manner 
that assures continuity of a full-range of acute care and long-term care 
services to poor elderly or disabled individuals eligible for benefits 
under this subchapter and under such plan.

(e) Restriction on enrollment for certain Medicare+Choice plans

                           (1) In general

        In the case of a Medicare+Choice religious fraternal benefit 
    society plan described in paragraph (2), notwithstanding any other 
    provision of this part to the contrary and in accordance with 
    regulations of the Secretary, the society offering the plan may 
    restrict the enrollment of individuals under this part to 
    individuals who are members of the church, convention, or group 
    described in paragraph (3)(B) with which the society is affiliated.

    (2) Medicare+Choice religious fraternal benefit society plan 
                                  described

        For purposes of this subsection, a Medicare+Choice religious 
    fraternal benefit society plan described in this paragraph is a 
    Medicare+Choice plan described in section 1395w-21(a)(2) of this 
    title that--
            (A) is offered by a religious fraternal benefit society 
        described in paragraph (3) only to members of the church, 
        convention, or group described in paragraph (3)(B); and
            (B) permits all such members to enroll under the plan 
        without regard to health status-related factors.

    Nothing in this subsection shall be construed as waiving any plan 
    requirements relating to financial solvency.

         (3) ``Religious fraternal benefit society'' defined

        For purposes of paragraph (2)(A), a ``religious fraternal 
    benefit society'' described in this section is an organization 
    that--
            (A) is described in section 501(c)(8) of the Internal 
        Revenue Code of 1986 and is exempt from taxation under section 
        501(a) of such Act;
            (B) is affiliated with, carries out the tenets of, and 
        shares a religious bond with, a church or convention or 
        association of churches or an affiliated group of churches;
            (C) offers, in addition to a Medicare+
        Choice religious fraternal benefit society plan, health coverage 
        to individuals not entitled to benefits under this subchapter 
        who are members of such church, convention, or group; and
            (D) does not impose any limitation on membership in the 
        society based on any health status-related factor.

                       (4) Payment adjustment

        Under regulations of the Secretary, in the case of individuals 
    enrolled under this part under a Medicare+Choice religious fraternal 
    benefit society plan described in paragraph (2), the Secretary shall 
    provide for such adjustment to the payment amounts otherwise 
    established under section 1395w-24 of this title as may be 
    appropriate to assure an appropriate payment level, taking into 
    account the actuarial characteristics and experience of such 
    individuals.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1859, as added Pub. L. 105-
33, title IV, Sec. 4001, Aug. 5, 1997, 111 Stat. 325; amended Pub. L. 
106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 523], Nov. 29, 1999, 113 
Stat. 1536, 1501A-387.)

                       References in Text

    Parts A and B of this subchapter, referred to in subsec. (b)(3)(A), 
are classified to section 1395c et seq. and section 1395j et seq., 
respectively, of this title.
    The Internal Revenue Code of 1986, referred to in subsec. (e)(3)(A), 
is classified generally to Title 26, Internal Revenue Code.


                               Amendments

    1999--Subsec. (e)(2). Pub. L. 106-113 substituted ``section 1395w-
21(a)(2) of this title'' for ``section 1395w-21(a)(2)(A) of this title'' 
in introductory provisions.

                  Section Referred to in Other Sections

    This section is referred to in sections 1395w-21, 1395w-22, 1395w-23 
of this title; title 26 section 138.
