42 USC 1395 - Contracts with Medicare+Choice organizations

1 So in original. Probably means subpar. (E) of par. (1).

an assessment of not more than the amount claimed by such plan or plan sponsor based upon the misrepresentation or falsified information involved, plus, with respect to a determination under paragraph (1)(B), double the excess amount charged in violation of such paragraph (and the excess amount charged shall be deducted from the penalty and returned to the individual concerned), and plus, with respect to a determination under paragraph (1)(D), $15,000 for each individual not enrolled as a result of the practice involved,

Editorial Notes

Amendments

2022—Subsec. (f)(3)(E). Puspan. L. 117–169 added subpar. (E).

2018—Subsec. (e)(5). Puspan. L. 115–271, § 6063(span), added par. (5).

Subsec. (f)(3)(D). Puspan. L. 115–271, § 2008(span), added subpar. (D).

2016—Subsec. (h)(3). Puspan. L. 114–255 added par. (3).

2010—Subsec. (d)(2)(A). Puspan. L. 111–148, § 6408(span)(1)(A), inserted “timely” before “inspect”.

Subsec. (d)(2)(B). Puspan. L. 111–148, § 6408(span)(1)(B), inserted “timely” before “audit and inspect”.

Subsec. (e)(4). Puspan. L. 111–152 added par. (4).

Subsec. (g)(1). Puspan. L. 111–148, § 6408(span)(2)(C), inserted at end of concluding provisions “The Secretary may provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph (2), if the Secretary determines that any employee or agent of such organization, or any provider or supplier who contracts with such organization, has engaged in any conduct described in subparagraphs (A) through (K) of this paragraph.”

Subsec. (g)(1)(H) to (K). Puspan. L. 111–148, § 6408(span)(2), added subpars. (H) to (K).

Subsec. (g)(2)(A). Puspan. L. 111–148, § 6408(span)(3), inserted “except with respect to a determination under subparagraph (E), an assessment of not more than the amount claimed by such plan or plan sponsor based upon the misrepresentation or falsified information involved,” after “for each such determination,”.

2008—Subsec. (d)(6). Puspan. L. 110–275, § 164(d)(2), added par. (6).

Subsec. (f)(3). Puspan. L. 110–275, § 171(span), added par. (3).

Subsec. (f)(3)(B). Puspan. L. 110–275, § 172(a)(2), added subpar. (B).

Subsec. (f)(3)(C). Puspan. L. 110–275, § 173(span), added subpar. (C).

2003—Subsec. (d)(1). Puspan. L. 108–173, § 222(l)(3)(C), substituted “and costs, including allowable costs under section 1395w–27a(c) of this title” for “, costs, and computation of the adjusted community rate”.

Subsec. (d)(4)(A)(ii). Puspan. L. 108–173, § 900(e)(1)(I), substituted “Secretary” for “Health Care Financing Administration”.

Subsec. (e)(2)(A). Puspan. L. 108–173, § 222(k)(1), inserted “and a PDP sponsor under part D” after “organization”.

Subsec. (e)(2)(B). Puspan. L. 108–173, § 222(k)(2), inserted “and each PDP sponsor with a contract under part D” after “contract under this part”, “or sponsor’s” after “organization’s”, and “, section 1395w–101(c) of this title,” after “information)”.

Subsec. (e)(2)(C). Puspan. L. 108–173, § 222(k)(3), inserted “and ending with fiscal year 2005” after “beginning with fiscal year 2001”, “and for each fiscal year beginning with fiscal year 2006 an amount equal to $200,000,000,” after “$100,000,000,”, and “and section 1395w–112(span)(3)(D) of this title” after “under this paragraph”.

Subsec. (e)(2)(D)(i). Puspan. L. 108–173, § 222(k)(4)(A), inserted “and section 1395w–101(c) of this title” after “section 1395w–21 of this title”.

Subsec. (e)(2)(D)(ii)(III). Puspan. L. 108–173, § 222(k)(4)(B), struck out “and” at end.

Subsec. (e)(2)(D)(ii)(IV). Puspan. L. 108–173, § 222(k)(4)(C), substituted “each succeeding fiscal year before fiscal year 2006; and” for “each succeeding fiscal year.”

Subsec. (e)(2)(D)(ii)(V). Puspan. L. 108–173, § 222(k)(4)(D), added subcl. (V).

Subsec. (e)(2)(F). Puspan. L. 108–173, § 222(k)(5), added subpar. (F).

Subsec. (e)(3). Puspan. L. 108–173, § 237(c), added par. (3).

Subsec. (i). Puspan. L. 108–173, § 222(j), designated existing provisions as par. (1), inserted heading, and added par. (2).

2000—Subsec. (g)(3)(D). Puspan. L. 106–554, § 1(a)(6) [title VI, § 623(a)], added subpar. (D).

Subsec. (i). Puspan. L. 106–554, § 1(a)(6) [title VI, § 617(a)], added subsec. (i).

1999—Subsec. (c)(4). Puspan. L. 106–113, § 1000(a)(6) [title V, § 513(span)(1)(B), (C)], designated existing provisions as subpar. (A), inserted heading, realigned margins, and added subpar. (B).

Puspan. L. 106–113, § 1000(a)(6) [title V, § 513(a), (span)(1)(A)], substituted “2-year period” for “5-year period” and “except as provided in subparagraph (B) and except in such other circumstances” for “except in circumstances”.

Subsec. (e)(2)(B). Puspan. L. 106–113, § 1000(a)(6) [title V, § 522(a)(1)], substituted “Any amounts collected shall be available without further appropriation to the Secretary for” for “Any amounts collected are authorized to be appropriated only for”.

Subsec. (e)(2)(C). Puspan. L. 106–113, § 1000(a)(6) [title V, § 522(a)(2)], amended heading and text of subpar. (C) generally. Prior to amendment, text read as follows: “For any fiscal year, the fees authorized under subparagraph (B) are contingent upon enactment in an appropriations act of a provision specifying the aggregate amount of fees the Secretary is directed to collect in a fiscal year. Fees collected during any fiscal year under this paragraph shall be deposited and credited as offsetting collections.”

Subsec. (e)(2)(D)(ii)(II). Puspan. L. 106–113, § 1000(a)(6) [title V, § 522(a)(3)(A)], struck out “and” after semicolon.

Subsec. (e)(2)(D)(ii)(III). Puspan. L. 106–113, § 1000(a)(6) [title V, § 522(a)(3)(B)], substituted “; and” for “and each subsequent fiscal year.”

Subsec. (e)(2)(D)(ii)(IV). Puspan. L. 106–113, § 1000(a)(6) [title V, § 522(a)(3)(C)], added subcl. (IV).

Subsec. (e)(2)(E). Puspan. L. 106–113, § 1000(a)(6) [title V, § 522(a)(4)], added subpar. (E).

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 2018 Amendment

Puspan. L. 115–271, title II, § 2008(e), Oct. 24, 2018, 132 Stat. 3931, provided that: “The amendments made by this section [amending this section and sections 1395w–112 and 1395y of this title] shall apply with respect to plan years beginning on or after January 1, 2020.”

Effective Date of 2010 Amendment

Amendment by section 6408(span)(1) of Puspan. L. 111–148 effective Mar. 23, 2010, and amendment by section 6408(span)(2), (3) of Puspan. L. 111–148 applicable to acts committed on or after Jan. 1, 2010, see section 6408(d) of Puspan. L. 111–148, set out as a note under section 1320a–7 of this title.

Effective Date of 2008 Amendment

Puspan. L. 110–275, title I, § 164(g), July 15, 2008, 122 Stat. 2575, provided that: “The amendments made by subsections (c)(1), (d), and (e)(1) [amending this section and section 1395w–28 of this title] shall apply to plan years beginning on or after January 1, 2010, and shall apply to all specialized Medicare Advantage plans for special needs individuals regardless of when the plan first entered the Medicare Advantage program under part C of title XVIII of the Social Security Act [42 U.S.C. 1395w–21 et seq.].”

Puspan. L. 110–275, title I, § 171(c), July 15, 2008, 122 Stat. 2580, provided that: “The amendments made by this section [amending this section and section 1395w–112 of this title] shall apply to plan years beginning on or after January 1, 2010.”

Puspan. L. 110–275, title I, § 172(span), July 15, 2008, 122 Stat. 2581, provided that: “The amendments made by this section [amending this section and section 1395w–112 of this title] shall apply to plan years beginning on or after January 1, 2010.”

Puspan. L. 110–275, title I, § 173(c), July 15, 2008, 122 Stat. 2581, provided that: “The amendments made by this section [amending this section and section 1395w–112 of this title] shall apply to plan years beginning on or after January 1, 2009.”

Effective Date of 2003 Amendment

Amendment by section 222(j), (k), (l)(3)(C) 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.

Amendment by section 237(c) of Puspan. L. 108–173 applicable to services provided on or after Jan. 1, 2006, and contract years beginning on or after such date, see section 237(e) of Puspan. L. 108–173, set out as a note under section 1320a–7span of this title.

Effective Date of 2000 Amendment

Puspan. L. 106–554, § 1(a)(6) [title VI, § 617(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–562, provided that: “The amendment made by subsection (a) [amending this section] shall apply with respect to years beginning with 2001.”

Puspan. L. 106–554, § 1(a)(6) [title VI, § 623(span)], Dec. 21, 2000, 114 Stat. 2763, 2763A–566, provided that: “The amendment made by subsection (a) [amending this section] shall apply to terminations occurring after the date of the enactment of this Act [Dec. 21, 2000].”

Effective Date of 1999 Amendment

Puspan. L. 106–113, div. B, § 1000(a)(6) [title V, § 513(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A–383, provided that: “The amendments made by this section [amending this section] apply to contract terminations occurring before, on, or after the date of the enactment of this Act [Nov. 29, 1999].”

Puspan. L. 106–113, div. B, § 1000(a)(6) [title V, § 522(span)], Nov. 29, 1999, 113 Stat. 1536, 1501A–387, provided that: “The amendments made by subsection (a) [amending this section] apply to fees charged on or after January 1, 2001. The Secretary of Health and Human Services may not increase the fees charged under section 1857(e)(2) of the Social Security Act (42 U.S.C. 1395w–27(e)(2)) for the 3-month period beginning with October 2000 above the level in effect during the previous 9-month period.”

Construction Relating to Additional Exceptions

Puspan. L. 106–113, div. B, § 1000(a)(6) [title V, § 513(span)(2)], Nov. 29, 1999, 113 Stat. 1536, 1501A–383, provided that: “Nothing in the amendment made by paragraph (1)(C) [amending this section] shall be construed to affect the authority of the Secretary of Health and Human Services to provide for exceptions in addition to the exception provided in such amendment, including exceptions provided under Operational Policy Letter #103 (OPL99.103).”

Delay in Authority To Terminate Contracts for Medicare Advantage Plans Failing To Achieve Minimum Quality Ratings

Puspan. L. 114–255, div. C, title XVII, § 17001(a), Dec. 13, 2016, 130 Stat. 1330, provided that: “Consistent with the studies provided under the IMPACT Act of 2014 (Public Law 113–185) [see Tables for classification], it is the intent of Congress—

“(1) to continue to study and request input on the effects of socioeconomic status and dual-eligible populations on the Medicare Advantage STARS rating system before reforming such system with the input of stakeholders; and

“(2) pending the results of such studies and input, to provide for a temporary delay in authority of the Centers for Medicare & Medicaid Services (CMS) to terminate Medicare Advantage plan contracts solely on the basis of performance of plans under the STARS rating system.”

Technical Correction to MA Private Fee-for-Service Plans

Puspan. L. 111–148, title III, § 3207, Mar. 23, 2010, 124 Stat. 459, provided that: “For plan year 2011 and subsequent plan years, to the extent that the Secretary of Health and Human Services is applying the 2008 service area extension waiver policy (as modified in the April 11, 2008, Centers for Medicare & Medicaid Services’ memorandum with the subject ‘2009 Employer Group Waiver-Modification of the 2008 Service Area Extension Waiver Granted to Certain MA Local Coordinated Care Plans’) to Medicare Advantage coordinated care plans, the Secretary shall extend the application of such waiver policy to employers who contract directly with the Secretary as a Medicare Advantage private fee-for-service plan under section 1857(i)(2) of the Social Security Act (42 U.S.C. 1395w–27(i)(2)) and that had enrollment as of October 1, 2009.”

Study of Multi-Year Contracts

Puspan. L. 108–173, title I, § 107(d), Dec. 8, 2003, 117 Stat. 2171, directed the Secretary of Health and Human Services to provide for a study on the feasibility and advisability of providing for contracting with PDP sponsors and MA organizations under this part and part D of this subchapter on a multi-year basis, and to submit to Congress a report on such study not later than Jan. 1, 2007.

Immediate Effective Date for Certain Requirements for Demonstrations

Puspan. L. 105–33, title IV, § 4002(g), Aug. 5, 1997, 111 Stat. 330, provided that: “Section 1857(e)(2) of the Social Security Act [42 U.S.C. 1395w–27(e)(2)] (requiring contribution to certain costs related to the enrollment process comparative materials) applies to demonstrations with respect to which enrollment is effected or coordinated under section 1851 of such Act [42 U.S.C. 1395w–21].”