I 108th CONGRESS 2d Session H. R. 5400 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.

1.

Short title

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

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.