Medicare Program; Health Maintenance Organization and Competitive Medical Plan National Coverage Decisions

摘要

This proposed rule would affect health maintenance organizations (HMOs) and competitive medical plans (CMPs) that contract with HCFA to furnish health care services to Medicare beneficiaries and to receive payment on a risk basis. These HMOs and CMPs would no longer be required to absorb the expense of furnishing a new or additional benefit if all the following conditions apply: The benefit was established by a national coverage decision (NCD); The cost of furnishing the service would be significant and was not taken into account in calculating the per capita rate to be paid by HCFA during the current calendar year; The NCD was not published until on or after the date of the announcement of the current calendar year's per capita rate of payment. This rule is necessary to implement section 4204(c) of the Omnibus Budget Reconciliation Act of 1990, commonly referred to as ``OBRA '90,'' which is effective for calendar years beginning on or after January 1, 1991. The purpose of the amendment is to encourage HMOs and CMPs to contract on a risk basis by ensuring that the actual scope of services covered under the contract would not change significantly during the year.