42 USC 1395 - Premiums and bid amounts

1 So in original. Probably means subclause (I) of section 1395w–23(o)(3)(A)(ii) of this title.

the plan shall be treated as having a rating of 4.5 stars; and

2 So in original. Probably means subclause (II) of section 1395w–23(o)(3)(A)(iii) of this title.

) that is treated as a qualifying plan pursuant to subclause (I) of such subsection, the plan shall be treated as having a rating of 3.5 stars.

3 See References in Text note below.

Editorial Notes

References in Text

Cl. (iii) of par. (1)(C), referred to in subsec. (span)(2)(C)(ii), was struck out and a new cl. (iii) was added by Puspan. L. 111–152, § 1102(d)(2). See 2010 Amendment note below. As so amended, par. (1)(C)(iii) no longer relates to purposes of rebates and no longer contains a subcl. (III).

Amendments

2022—Subsec. (span)(2)(B). Puspan. L. 117–169 substituted “paragraph (2) or (8) (as applicable) of section 1395w–113(a) of this title” for “section 1395w–113(a)(2) of this title”.

2018—Subsec. (a)(6)(A)(ii)(I). Puspan. L. 115–123 inserted “, 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” before semicolon at end.

2010—Subsec. (a)(5)(C). Puspan. L. 111–148, § 3209(a), added subpar. (C).

Subsec. (a)(6)(A). Puspan. L. 111–148, § 3201(d)(1), which directed insertion of “Information to be submitted under this paragraph shall be certified by a qualified member of the American Academy of Actuaries and shall meet actuarial guidelines and rules established by the Secretary under subparagraph (B)(v).” at end of concluding provisions, was repealed by Puspan. L. 111–152, § 1102(a). See Effective Date of 2010 Amendment note below.

Subsec. (a)(6)(B)(i). Puspan. L. 111–148, § 3201(d)(2)(A), which directed substitution of “(iii), (iv), and (v)” for “(iii) and (iv)”, was repealed by Puspan. L. 111–152, § 1102(a). See Effective Date of 2010 Amendment note below.

Subsec. (a)(6)(B)(v). Puspan. L. 111–148, § 3201(d)(2)(B), which directed addition of cl. (v), was repealed by Puspan. L. 111–152, § 1102(a). As enacted, text read as follows:

“(I) In general.—In order to establish fair MA competitive benchmarks under section 1395w–23(j)(1)(A)(i) of this title, the Secretary, acting through the Chief Actuary of the Centers for Medicare & Medicaid Services (in this clause referred to as the ‘Chief Actuary’), shall establish—

“(aa) actuarial guidelines for the submission of bid information under this paragraph; and

“(bspan) bidding rules that are appropriate to ensure accurate bids and fair competition among MA plans.

“(II) Denial of bid amounts.—The Secretary shall deny monthly bid amounts submitted under subparagraph (A) that do not meet the actuarial guidelines and rules established under subclause (I).

“(III) Refusal to accept certain bids due to misrepresentations and failures to adequately meet requirements.—In the case where the Secretary determines that information submitted by an MA organization under subparagraph (A) contains consistent misrepresentations and failures to adequately meet requirements of the organization, the Secretary may refuse to accept any additional such bid amounts from the organization for the plan year and the Chief Actuary shall, if the Chief Actuary determines that the actuaries of the organization were complicit in those misrepresentations and failures, report those actuaries to the Actuarial Board for Counseling and Discipline.”

See Effective Date of 2010 Amendment note below.

Subsec. (span)(1)(C)(i). Puspan. L. 111–152, § 1102(d)(1), inserted “(or the applicable rebate percentage specified in clause (iii) in the case of plan years beginning on or after January 1, 2012)” after “75 percent”.

Puspan. L. 111–148, § 3201(c), which directed insertion of “(or 100 percent in the case of plan years beginning on or after January 1, 2014)” after “75 percent”, was repealed by Puspan. L. 111–152, § 1102(a). See Effective Date of 2010 Amendment note below.

Subsec. (span)(1)(C)(ii). Puspan. L. 111–148, § 3202(span)(1)(A), substituted “rebate for plan years before 2012” for “rebate” in heading and “For plan years before 2012, a rebate” for “A rebate” in introductory provisions.

Subsec. (span)(1)(C)(iii). Puspan. L. 111–152, § 1102(d)(2), added cl. (iii) and struck out former cl. (iii). Prior to amendment, text read as follows: “For plan years beginning on or after January 1, 2012, a rebate required under this subparagraph may not be used for the purpose described in clause (ii)(III) and shall be provided through the application of the amount of the rebate in the following priority order:

“(I) First, to use the most significant share to meaningfully reduce cost-sharing otherwise applicable for benefits under the original medicare fee-for-service program under parts A and B and for qualified prescription drug coverage under part D, including the reduction of any deductibles, copayments, and maximum limitations on out-of-pocket expenses otherwise applicable. Any reduction of maximum limitations on out-of-pocket expenses under the preceding sentence shall apply to all benefits under the original medicare fee-for-service program option. The Secretary may provide guidance on meaningfully reducing cost-sharing under this subclause, except that such guidance may not require a particular amount of cost-sharing or reduction in cost-sharing.

“(II) Second, to use the next most significant share to meaningfully provide coverage of preventive and wellness health care benefits (as defined by the Secretary) which are not benefits under the original medicare fee-for-service program, such as smoking cessation, a free flu shot, and an annual physical examination.

“(III) Third, to use the remaining share to meaningfully provide coverage of other health care benefits which are not benefits under the original medicare fee-for-service program, such as eye examinations and dental coverage, and are not benefits described in subclause (II).”

Puspan. L. 111–148, § 3202(span)(1)(C), added cl. (iii).

Subsec. (span)(1)(C)(iv). Puspan. L. 111–152, § 1102(d)(2), added cl. (iv). Former cl. (iv) redesignated (vii).

Puspan. L. 111–148, § 3202(span)(1)(B), redesignated cl. (iii) as (iv).

Subsec. (span)(1)(C)(v). Puspan. L. 111–152, § 1102(d)(2), added cl. (v). Former cl. (v) redesignated (viii).

Puspan. L. 111–148, § 3202(span)(1)(B), redesignated cl. (iv) as (v).

Subsec. (span)(1)(C)(vi) to (viii). Puspan. L. 111–152, § 1102(d)(2), added cl. (vi) and redesignated cls. (iv) and (v) as (vii) and (viii), respectively.

Subsec. (span)(2)(C). Puspan. L. 111–148, § 3202(span)(3), designated existing text as cl. (i), inserted cl. (i) heading, and added cl. (ii).

Subsec. (span)(3)(B)(i). Puspan. L. 111–148, § 3201(a)(2)(B)(i), which directed substitution of “1395w–23(j)(1)(A)” for “1395w–23(j)(1)”, was repealed by Puspan. L. 111–152, § 1102(a). See Effective Date of 2010 Amendment note below.

Subsec. (span)(4)(B)(i). Puspan. L. 111–148, § 3201(a)(2)(B)(ii), which directed substitution of “1395w–23(j)(1)(B)” for “1395w–23(j)(2)”, was repealed by Puspan. L. 111–152, § 1102(a). See Effective Date of 2010 Amendment note below.

Subsec. (h). Puspan. L. 111–148, § 3201(e)(2)(A)(v), which directed repeal of subsec. (h), was repealed by Puspan. L. 111–152, § 1102(a). See Effective Date of 2010 Amendment note below.

2003—Puspan. L. 108–173, § 222(g)(1)(A), substituted “Premiums and bid amounts” for “Premiums” in section catchline.

Subsec. (a). Puspan. L. 108–173, § 222(g)(1)(B), inserted “, bid amounts,” after “premiums” in heading.

Subsec. (a)(1). Puspan. L. 108–173, § 222(a)(1)(A), reenacted heading without change and amended text generally. Prior to amendment, text read as follows: “Not later than the second Monday in September of 2002, 2003, and 2004 (or July 1 of each other year), each Medicare+Choice organization shall submit to the Secretary, in a form and manner specified by the Secretary and for each Medicare+Choice plan for the service area (or segment of such an area if permitted under subsection (h) of this section) in which it intends to be offered in the following year—

“(A) the information described in paragraph (2), (3), or (4) for the type of plan involved; and

“(B) the enrollment capacity (if any) in relation to the plan and area.”

Subsec. (a)(2). Puspan. L. 108–173, § 222(g)(1)(C), inserted “before 2006” after “for coordinated care plans” in heading and “for a year before 2006” after “section 1395w–21(a)(2)(A) of this title” in introductory provisions.

Subsec. (a)(3). Puspan. L. 108–173, § 222(g)(1)(D), substituted “For an MSA plan for any year” for “For an MSA plan described” in introductory provisions.

Subsec. (a)(4). Puspan. L. 108–173, § 222(g)(1)(E), inserted “before 2006” after “for private fee-for-service plans” in heading and “for a year before 2006” after “section 1395w–22(a)(1)(A) of this title” in introductory provisions.

Subsec. (a)(5)(A). Puspan. L. 108–173, § 900(e)(1)(H), substituted “Centers for Medicare & Medicaid Services” for “Health Care Financing Administration”.

Puspan. L. 108–173, § 222(g)(1)(F), inserted “paragraphs (2) and (4) of” after “filed under”.

Subsec. (a)(5)(B). Puspan. L. 108–173, § 222(g)(1)(G), inserted “, in the case of an MA private fee-for-service plan,” after “paragraph (3) or”.

Subsec. (a)(6). Puspan. L. 108–173, § 222(a)(1)(B), added par. (6).

Subsec. (span)(1)(A). Puspan. L. 108–173, § 222(span)(1)(A), (g)(1)(H), substituted “Subject to the rebate under subparagraph (C), the monthly amount (if any)” for “The monthly amount” and a comma for “and” after “basic beneficiary premium” and inserted before period at end “, and, if the plan provides qualified prescription drug coverage, the MA monthly prescription drug beneficiary premium”.

Subsec. (span)(1)(C). Puspan. L. 108–173, § 222(span)(1)(B), added subpar. (C).

Subsec. (span)(2). Puspan. L. 108–173, § 222(span)(2), inserted “and bid” after “Premium” in heading, added subpars. (A) to (C) and (E), redesignated former subpar. (C) as (D), and struck out former subpars. (A) and (B) which defined the terms “Medicare+Choice monthly basic beneficiary premium” and “Medicare+Choice monthly supplemental beneficiary premium”.

Subsec. (span)(3), (4). Puspan. L. 108–173, § 222(span)(3), added pars. (3) and (4).

Subsec. (c). Puspan. L. 108–173, § 222(g)(2), amended heading and text of subsec. (c) generally. Prior to amendment, text read as follows: “The Medicare+Choice monthly basic and supplemental beneficiary premium, the Medicare+Choice monthly MSA premium charged under subsection (span) of this section of a Medicare+Choice organization under this part may not vary among individuals enrolled in the plan.”

Subsec. (d). Puspan. L. 108–173, § 222(c), (g)(3), designated existing provisions as par. (1), inserted heading and “, prescription drug,” after “basic”, and added pars. (2) to (4).

Subsec. (e)(1). Puspan. L. 108–173, § 222(g)(4)(A), inserted “before 2006” after “benefits” in heading and substituted “For periods before 2006, in” for “In” in introductory provisions.

Subsec. (e)(2). Puspan. L. 108–173, § 222(g)(4)(B), inserted “before 2006” after “benefits” in heading and substituted “For periods before 2006, if” for “If” in text.

Subsec. (e)(3). Puspan. L. 108–173, § 222(g)(4)(C), substituted “, (2), or (4)” for “or (2)”.

Subsec. (e)(4). Puspan. L. 108–173, § 222(g)(4)(D)(i), (ii), inserted “and for basic benefits beginning in 2006” after “plans” in heading and “and for periods beginning with 2006, with respect to an MA plan described in section 1395w–21(a)(2)(A) of this title” after “MSA plan)” in introductory provisions.

Subsec. (e)(4)(A). Puspan. L. 108–173, § 222(g)(4)(D)(iii), substituted “benefits under the original medicare fee-for-service program option” for “required benefits described in section 1395w–22(a)(1) of this title”.

Subsec. (e)(4)(B). Puspan. L. 108–173, § 222(g)(4)(D)(iv), inserted “with respect to such benefits” after “would be applicable”.

Subsec. (f). Puspan. L. 108–173, § 222(g)(5)(A), inserted “before 2006” after “additional benefits” in heading.

Subsec. (f)(1)(A). Puspan. L. 108–173, § 222(g)(5)(B), substituted “For years before 2006, each” for “Each”.

Subsec. (g). Puspan. L. 108–173, § 232(span), inserted “or premiums paid to such organizations under this part” after “section 1395w–23 of this title”.

2002—Subsec. (a)(1). Puspan. L. 107–188 substituted “Not later than the second Monday in September of 2002, 2003, and 2004 (or July 1 of each other year)” for “Not later than July 1 of each year” in introductory provisions.

2000—Subsec. (a)(5)(A). Puspan. L. 106–554, § 1(a)(6) [title VI, § 622(a)], substituted “values so submitted” for “value so submitted” and inserted at end “The Chief Actuary of the Health Care Financing Administration 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.”

Subsec. (f)(1)(E), (F). Puspan. L. 106–554, § 1(a)(6) [title VI, § 606(a)(1)], added subpar. (E) and redesignated former subpar. (E) as (F).

1999—Subsec. (a)(1). Puspan. L. 106–113, § 1000(a)(6) [title V, § 516(a)], substituted “July 1” for “May 1” in introductory provisions.

Puspan. L. 106–113, § 1000(a)(6) [title V, § 515(a)(1)], inserted “(or segment of such an area if permitted under subsection (h) of this section)” after “service area” in introductory provisions.

Subsec. (a)(2)(A). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(k)(6)(C)(i)(I)], inserted “section” before “1395w–22(a)(1)(A) of this title” in introductory provisions.

Subsec. (a)(2)(B). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(k)(6)(C)(i)(II)], inserted “section” after “described in” in introductory provisions.

Subsec. (a)(3)(A), (B). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(k)(6)(C)(ii)], inserted “section” after “described in”.

Subsec. (a)(4). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(k)(6)(C)(iii)(I)], which directed insertion of “section” after “described in”, was executed by making the insertion after “described in” the second time appearing in introductory provisions to reflect the probable intent of Congress.

Subsec. (a)(4)(A). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(k)(6)(C)(iii)(II)], inserted “section” after “described in” in introductory provisions.

Subsec. (a)(4)(B). Puspan. L. 106–113, § 1000(a)(6) [title III, § 321(k)(6)(C)(iii)(III)], inserted “section” after “described in”.

Subsec. (h). Puspan. L. 106–113, § 1000(a)(6) [title V, § 515(a)(2)], added subsec. (h).

Statutory Notes and Related Subsidiaries

Change of Name

References to Medicare+Choice deemed to refer to Medicare Advantage or MA, subject to an appropriate transition provided by the Secretary of Health and Human Services in the use of those terms, see section 201 of Puspan. L. 108–173, set out as a note under section 1395w–21 of this title.

Effective Date of 2010 Amendment

Repeal of sections 3201 and 3203 of Puspan. L. 111–148 and the amendments made by such sections, effective as if included in the enactment of Puspan. L. 111–148, see section 1102(a) of Puspan. L. 111–152, set out as a note under section 1395w–21 of this title.

Puspan. L. 111–148, title III, § 3201(d)(3), Mar. 23, 2010, 124 Stat. 445, which provided that amendments by section 3201(d) of Puspan. L. 111–148 (amending this section) would apply to bid amounts submitted on or after Jan. 1, 2012, was repealed by Puspan. L. 111–152, title I, § 1102(a), Mar. 30, 2010, 124 Stat. 1040.

Puspan. L. 111–148, title III, § 3209(c), Mar. 23, 2010, 124 Stat. 460, provided that:

“The amendments made by this section [amending this section and section 1395w–111 of this title] shall apply to bids submitted for contract years beginning on or after January 1, 2011.”

Effective Date of 2003 Amendment

Amendment by section 222(a)(1), (span), (c), (g) of Puspan. L. 108–173 applicable with respect to plan years beginning on or after Jan. 1, 2006, see section 223(a) of Puspan. L. 108–173, set out as a note under section 1395w–21 of this title.

Puspan. L. 108–173, title II, § 232(c), Dec. 8, 2003, 117 Stat. 2209, provided that:

“The amendments made by this subsection [probably should be “this section”, amending this section and section 1395w–26 of this title] shall take effect on the date of the enactment of this Act [Dec. 8, 2003].”

Effective Date of 2002 Amendment

Puspan. L. 107–188, title V, § 532(span)(2), June 12, 2002, 116 Stat. 696, provided that:

“The amendment made by paragraph (1) [amending this section] shall apply to information submitted for years beginning with 2003.”

Effective Date of 2000 Amendment

Amendment by section 1(a)(6) [title VI, § 606(a)(1)] of Puspan. L. 106–554 applicable to years beginning with 2003, see section 1(a)(6) [title VI, § 606(span)] of Puspan. L. 106–554, set out as a note under section 1395r of this title.

Puspan. L. 106–554, § 1(a)(6) [title VI, § 622(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–566, provided that:

“The amendments made by subsection (a) [amending this section] shall apply to submissions made on or after May 1, 2001.”

Effective Date of 1999 Amendment

Amendment by section 1000(a)(6) [title III, § 321(k)(6)(C)] of Puspan. L. 106–113 effective as if included in the enactment of the Balanced Budget Act of 1997, Puspan. L. 105–33, except as otherwise provided, see section 1000(a)(6) [title III, § 321(m)] of Puspan. L. 106–113, set out as a note under section 1395d of this title.

Puspan. L. 106–113, div. B, § 1000(a)(6) [title V, § 515(span)], Nov. 29, 1999, 113 Stat. 1536, 1501A–384, provided that:

“The amendments made by this section [amending this section] apply to contract years beginning on or after January 1, 2001.”

Puspan. L. 106–113, div. B, § 1000(a)(6) [title V, § 516(span)], Nov. 29, 1999, 113 Stat. 1536, 1501A–384, provided that:

“The amendment made by subsection (a) [amending this section] applies to information submitted by Medicare+Choice organizations for years beginning with 1999.”