[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5400 Introduced in House (IH)]






108th CONGRESS
  2d Session
                                H. R. 5400

     To provide for reimbursement of enrollees in the Medicare PPO 
 Demonstration Project for expenses inappropriately incurred in being 
          provided coverage through out-of-network providers.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           November 19, 2004

  Mr. Cardin introduced the following bill; which was referred to the 
Committee on Ways and Means, and in addition to the Committee on Energy 
    and Commerce, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
     To provide for reimbursement of enrollees in the Medicare PPO 
 Demonstration Project for expenses inappropriately incurred in being 
          provided coverage through out-of-network providers.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Medicare PPO Fairness Act of 2004''.

SEC. 2. REIMBURSEMENT OF ENROLLEES IN THE MEDICARE PPO DEMONSTRATION 
              PROJECT FOR EXPENSES FOR COVERED BENEFITS PROVIDED 
              THROUGH OUT-OF-NETWORK PROVIDERS.

    (a) Notice.--The Secretary of Health and Human Services shall 
provide written notice to each individual who is, or has been, enrolled 
in the Medicare PPO Demonstration Project of the following:
            (1) The fact that enrollees under such project are, and 
        have been, eligible for coverage of services whether the 
        services were provided by in-network or out-of-network 
        providers (pursuant to section 1859(b)(2) of the Social 
        Security Act (42 U.S.C. 1395w-28(b)(2)).
            (2) There is a procedure, established under subsection (b), 
        to provide for reimbursement for claims for services that 
        should be (or have been) covered but were not covered because 
        of their provision by an out-of-network provider in violation 
        of the requirement described in paragraph (1).
    (b) Procedure for Reimbursement.--The Secretary shall establish a 
procedure for reimbursement of enrollees under the Medicare PPO 
Demonstration Project for claims for services furnished before January 
1, 2005, that should be (or have been) covered but were not covered 
because of their provision by an out-of-network provider in violation 
of the requirement described in subsection (a)(1).
    (c) Adjustment in Capitation Rates.--The Secretary shall provide 
for an adjustment in the capitation rates for plans under the Medicare 
PPO Demonstration Project for months in 2005 so as to reduce payment 
under such rates, in the aggregate, by the aggregate amount of payments 
the Secretary estimates will be paid under subsection (b).
    (d) Definitions.--For purposes of this section:
            (1) Medicare ppo demonstration project defined.--The term 
        ``Medicare PPO Demonstration Project'' means the Medicare 
        Preferred Provider Organization (PPO) Demonstration conducted 
        by the Secretary under the authority of section 402(a) of the 
        Social Security Amendments of 1967 (Public Law 90-248; 42 
        U.S.C. 1395b-1(a)).
            (2) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.
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