[Congressional Record Volume 150, Number 135 (Saturday, November 20, 2004)]
[Extensions of Remarks]
[Page E2115]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




         INTRODUCTION OF THE MEDICARE PPO FAIRNESS ACT OF 2004

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                        HON. BENJAMIN L. CARDIN

                              of maryland

                    in the house of representatives

                       Friday, November 19, 2004

  Mr. CARDIN. Mr. Speaker, I rise today to introduce the Medicare PPO 
Fairness Act. This bill addresses an urgent problem facing 98,000 
Medicare beneficiaries whose legal rights to health care services have 
been denied. Today may be the last day of the 108th Congress, and so I 
will reintroduce this measure in January in the hope that members will 
consider it early next year.
  In 2003, the Centers for Medicare and Medicaid Services, CMS, began a 
Medicare PPO Demonstration to test the efficiency of different types of 
private health plans in the Medicare program. Preferred provider 
organizations, PPOs, are forms of managed care that are somewhat less 
restrictive than health maintenance organizations, HMOs. Generally 
speaking, in an HMO model, patients are covered only for services 
rendered by doctors, hospitals and other providers who are ``in-
network,'' meaning on the plan's approved list. By contrast, in a PPO, 
patients are covered not only for services rendered by providers on the 
approved list, but also for other providers, but they must usually pay 
additional out-of-pocket costs. For purposes of this demonstration 
program, Congress gave CMS flexibility with respect to payments to 
these private plans but not with respect to the benefits that they must 
provide to seniors.
  We have recently learned from the General Accountability Office, GAO, 
that CMS exceeded its authority. According to a report issued in late 
September, the Centers for Medicare and Medicaid Services, CMS, 
improperly gave private health plans permission to limit beneficiaries' 
access to care from providers who were not in the plans' networks. GAO 
found that 29 of the 33 PPO plans in the demonstration told seniors 
that if they sought covered services from providers not in their 
network they would be liable for all charges. As of this year, more 
than 98,000 seniors were enrolled in demonstration PPO plans, including 
3,000 seniors in my home state of Maryland, so thousands of seniors 
have been affected by these restrictions.
  In the GAO report, CMS Administrator Mark McClellan concurred with 
GAO's findings and said his agency would instruct all participating 
plans that they must cover out-of-network as well as in-network care. 
That is the right thing for Dr. McClellan to do, but it is not 
sufficient. I remain concerned about the thousands of seniors who for 
the past two years were told in error that they had no right to see 
their provider of choice. There are also countless providers who were 
improperly denied the opportunity to treat beneficiaries--and therefore 
lost income--simply because they were not on the PPG's provider panel. 
Finally, I remain concerned about those seniors who paid out-of-pocket 
for medical care--including routine physical examinations, home health 
services and skilled nursing care--that Medicare should have covered. 
It is Medicare's responsibility to reimburse for those services.
  The bill that I am filing today would accomplish two things: first, 
it would ensure that seniors in Medicare PPOs are aware of their 
rights. It would require the Secretary of HHS to immediately notify 
each of the approximately 98,000 PPO enrollees that they are entitled 
to receive services from both in-network and out-of-network providers. 
I learned about the GAO's findings from the newspapers. Our seniors 
should not have to rely on the press to learn what benefits they are 
entitled to from Medicare.
  Second, my bill would require the Medicare program to reimburse those 
beneficiaries in PPOs who erroneously paid out-of-pocket for care from 
out-of-network providers. Those seniors who enrolled in the Medicare 
PPO demonstration program deserve to receive all the benefits they are 
legally entitled to, and they should be made whole. This bill is budget 
neutral. It provides for all payments for reimbursable services 
rendered in 2003 and 2004 to be deducted from planned 2005 payments to 
Medicare PPOs, money that has already been allocated for next year.
  Mr. Speaker, I think all members would agree that our seniors should 
have access to a full range of choices within the Medicare program, and 
that Congress should ensure that seniors receive all the benefits to 
which they are entitled. My bill will help guarantee that in the 
demonstration program now in operation at CMS, seniors get the benefits 
that Congress intended. I hope this bill will be enacted quickly when 
the 109th Congress convenes next year, and I urge my colleagues to 
support this measure.




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