Medicare Program; Limits on Payment to Health Maintenance Organizations (HMOs), Competitive Medical Plans (CMPs), and Health Care Prepayment Plans (HCPPs)

Resumo

This proposed rule would remove the provision (never implemented) that would have made the adjusted average per capita cost (AAPCC) the absolute limit on payment for services furnished to Medicare enrollees by an HMO or CMP with a cost contract. This change is necessary to conform our rules to the interpretation of the statute as set forth in court decisions relating to payment of reasonable costs. This rule would also provide for using the AAPCC as a presumptive limit, subject to exceptions, for HMOs and CMPs with cost contracts, and for health care prepayment plans (HCPPs) that furnish inpatient hospital care as well as part B services; Eliminate the effective incentives exception that is currently available to HCPPs; Require HCPPs that do not furnish inpatient hospital services to document that their costs do not exceed what Medicare's cost would have been if the Medicare beneficiaries who received the services had not enrolled in the HCPP; and revise the rules for reporting costs.