[Federal Register Volume 59, Number 47 (Thursday, March 10, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-5327]


[[Page Unknown]]

[Federal Register: March 10, 1994]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Part 417

[OCC-011-P]
RIN 0938-AE63

 

Medicare Program; Post-Contract Protections and Other Coordinated 
Care Issues

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Proposed rule.

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SUMMARY: This proposed rule would amend HCFA regulations to provide 
that--
     A health maintenance organization (HMO) or a competitive 
medical plan (CMP) that has a Medicare risk or cost contract with HCFA 
and that ceases to furnish services, for any reason, must provide, for 
enrollees who return to the fee-for-service payment system, protection 
against loss of coverage because of a preexisting condition exclusion 
clause in the enrollee's replacement Medicare supplement insurance 
policy.
     If the Medicare risk contract of an HMO or CMP is 
terminated, not renewed, or renewed with a reduced service area, all 
other Medicare risk-contracting organizations operating in any part of 
the service area must provide a 30-day special open enrollment period 
for the benefit of the affected enrollees.
     All contracting HMOs and CMPs, and all health care 
prepayment plans (HCPPs), must furnish to Medicare beneficiaries at the 
time of application a signed copy of the enrollment application form.
     An HCPP must also meet all the other requirements that 
contracting HMOs and CMPs must meet in handling applications.
     These amendments would provide post-contract protections 
for Medicare enrollees of HMOs and CMPs that cease to provide services 
under a Medicare contract and would also strengthen the application 
procedures for HMOs, CMPs, and HCPPs. The first two amendments 
implement, respectively, section 4011 of the Omnibus Budget 
Reconciliation Act of 1987 and section 6206 of the Omnibus Budget 
Reconciliation Act of 1989.
     In addition, this proposed rule would provide that all 
HMOs and CMPs with risk contracts must submit their Adjusted Community 
Rate (ACR) proposals to HCFA not later than 60 days (rather than 45) 
days before the beginning of a contract period. The earlier submission 
date for the ACR proposals is necessary to provide more time for HCFA 
to review and evaluate the material.

DATES: Written comments will be considered if we receive them at the 
appropriate address, as provided below, no later than 5 p.m on May 9, 
1994.

ADDRESSES: Mail comments (original and three copies) to the following 
address: Health Care Financing Administration, Department of Health and 
Human Services, Attention: OCC-011-P, P.O. Box 26688, Baltimore, MD 
21207.
    If you prefer, you may deliver your written comments (original and 
three copies) to one of the following addresses: Room 309-G, Hubert H. 
Humphrey Building, 200 Independence Ave., SW., Washington, DC 20201, or 
room 132, East High Rise Building, 6325 Security Boulevard, Baltimore, 
MD 21207.
    If comments concern information collection or recordkeeping 
requirements, please address a copy of comments to: Office of 
Management and Budget, Office of Information and Regulatory Affairs, 
room 3001, New Executive Office Building, Washington, DC 20503, 
Attention: Allison Herron Eydt.
    Due to staffing and resource limitations, we cannot accept comments 
by facsimile (FAX) transmission.
    In commenting, please refer to file code OCC-011-P. Comments 
received timely will be available for public inspection as they are 
received, beginning approximately three weeks after publication of this 
document, in Room 309-G of the Department's offices at 200 Independence 
Avenue, SW., Washington, DC, on Monday through Friday of each week from 
8:30 a.m. to 5 p.m., (202) 690-7890.

FOR FURTHER INFORMATION CONTACT: Tracy Jensen, (202) 619-2158.

SUPPLEMENTARY INFORMATION:

I. Background

A. Health Maintenance Organizations and Competitive Medical Plans

    Health maintenance organizations (HMOs) and competitive medical 
plans (CMPs) are entities that provide specified health care services, 
in a defined geographic area, to persons who are enrolled in the 
entities, in exchange for a predetermined, fixed, periodic premium 
payment. When these entities meet the requirements of section 1876(b) 
of the Social Security Act (the Act), they become eligible to contract 
with HCFA to provide and be paid for services furnished to Medicare 
enrollees. These entities may contract either on a ``risk'' basis or a 
``cost'' basis.
    When HMOs or CMPs contract with HCFA on a risk basis, HCFA makes 
advance monthly payments for each enrolled Medicare beneficiary, and 
there is no adjustment at the end of the contract year. The per capita 
rate of payment for each class of enrollees under a risk contract is 
equal to 95 percent of the Adjusted Average Per Capita Cost (AAPCC). 
The AAPCC is the actuarial estimate made by HCFA, before an 
organization's contract period, of what the average per capita cost to 
the Medicare program would be for each class of Medicare enrollees if 
they received covered services other than through the organization or 
another organization in the same geographic area. A class of Medicare 
enrollees is a grouping of an organization's Medicare enrollees that 
HCFA constructs on the basis of actuarial factors such as age, sex, 
Medicaid status, institutional status, and other relevant factors that 
have a significant effect on the use and costs of health care services.
    HMOs or CMPs that contract to be paid on a cost basis also receive 
monthly advance payments. However, these payments are based on a 
general overall budget submitted by the HMO or CMP and are subject to 
an annual reconciliation so that payments cover the reasonable costs of 
the specific services that they actually provide to Medicare enrollees.
    An HMO or CMP that contracts to be paid on a risk basis must 
provide to enrollees all Medicare Part A and Part B services (except 
hospice services) that are available to beneficiaries who reside in the 
geographic area served by the HMO or CMP. A Medicare beneficiary who 
enrolls in a risk HMO or CMP must obtain all services directly from or 
under arrangements made by the HMO or CMP. The HMO or CMP is 
financially responsible for emergency services and urgently needed 
services obtained from other sources while the beneficiary is traveling 
or temporarily outside the service area of that HMO or CMP.
    An HMO or CMP that contracts with HCFA on a cost basis must offer 
the same Medicare services as a risk HMO or CMP. However, the cost plan 
enrollee may obtain any Medicare covered services outside the HMO or 
CMP and have those services paid for by Medicare intermediaries or 
carriers, subject to Medicare deductibles and coinsurance.
    Initial contracts between HCFA and an HMO or CMP must be for at 
least 1 year, but not more than 23 months, and any contract renewal 
must be for a period of 1 year. A contract is renewed automatically 
unless HCFA or the HMO or CMP decides not to renew. If the HMO or CMP 
decides not to renew its contract, it must give written notice to HCFA 
at least 90 days before the end of the current contract period and 
notify each Medicare enrollee by mail at least 60 days before the end 
of the contract period. It must also provide 30 days notice to the 
general public by publishing an announcement in a local newspaper. If 
HCFA decides not to renew, it must provide like notice to the Medicare 
enrollees, the HMO or CMP, and the general public.
    A contract can be terminated before its expiration by mutual 
consent or unilaterally by either party if certain conditions are 
present, generally if the other party fails to perform its obligations. 
The terminating party is responsible for making the necessary 
notifications.
    Each Medicare beneficiary who wishes to enroll in an HMO or CMP is 
required to complete an enrollment application form. 42 CFR 417.430 
controls the format and content of the enrollment application form and 
prescribes procedures for handling applications. However, it does not 
require the HMO or CMP to furnish the beneficiary with a copy of the 
executed application at the time of enrollment.

B. Health Care Prepayment Plans

    A health care prepayment plan (HCPP) is a prepaid group medical 
plan that elects to receive Medicare payment from HCFA for Part B 
services on a reasonable cost basis under section 1833(a)(1)(A) of the 
Act. The regulations concerning Medicare payment to HCPPs are located 
at 42 CFR part 417. Under Sec. 417.800(b)(1), an organization wishing 
to participate in Medicare as an HCPP is required to enter into a 
written agreement with HCFA to furnish physicians' services, through 
employee physicians or contracting physicians, and to furnish other 
covered Part B services through Medicare qualified providers and 
suppliers. HCFA pays an HCPP directly for physician's services 
furnished to its Medicare enrollees through plan employees or 
contracting physicians, and for other Part B services furnished under 
arrangements with Medicare certified suppliers. Payment for Part B 
services furnished to an HCPP enrollee by a provider of services such 
as a hospital, as well as payment for any Part A services, is made 
directly to the provider.
    Section 417.801 sets forth the requirements for written agreements 
between HCFA and an HCPP, but it contains no specific procedures 
concerning application by Medicare beneficiaries for enrollment in an 
HCPP.

II. Supplemental Exclusion Coverage Upon Termination of Contract

A. Current Policy

    Under the Medicare fee-for-service payment system, beneficiaries 
are liable for deductible and coinsurance amounts associated with 
certain Medicare covered services. Beneficiaries may insure for some or 
all of these out-of-pocket expenses by purchasing a Medicare supplement 
policy, generally referred to as a Medigap policy, from a private 
insurance company. Medigap policies supplement Medicare coverage by 
reimbursing the beneficiary for some or all coinsurance expenses and 
may also reimburse for deductible expenses as well, depending on the 
terms of the policy. The Medigap policy may also pay for certain 
additional services or costs that are not covered by Medicare.
    Medigap policies sometimes contain a preexisting condition 
exclusion clause, that is, a provision that the policy will not cover 
its share of expenses related to a preexisting condition, until a 
specified waiting period has elapsed. The waiting period for coverage 
of a preexisting condition may not exceed 6 months. The Medigap policy 
may not define a preexisting condition more restrictively than a 
condition for which medical advice was given or treatment was 
recommended by or received from a physician within 6 months before the 
effective date of coverage.
    In the HMO or CMP setting, HCFA makes a monthly payment directly to 
the HMO or CMP to cover all mandated Medicare benefits, less deductible 
and coinsurance amounts. The HMO or CMP is permitted to charge the 
beneficiary a premium or other amounts such as copayments in place of 
the regular Medicare deductible and coinsurance amounts. When Medicare 
beneficiaries enroll in an HMO or CMP, they are advised to cancel their 
Medigap insurance policy because the HMO or CMP supplemental coverage 
is similar to the coverage afforded by Medigap policies. In addition, 
if the enrollee did not cancel the Medigap policy, the HMO or CMP could 
be considered in violation of section 1882(d)(3)(A) of the Act, which 
makes it unlawful for a person to sell or issue a health insurance 
policy to any individual entitled to benefits under Part A or under 
Part B of Medicare with knowledge that the policy duplicates health 
benefits to which the individual is otherwise entitled.
    If the HMO's or CMP's Medicare risk contract is terminated, not 
renewed, or renewed with a reduced service area, the affected Medicare 
enrollees would be transferred into the fee-for-service payment system 
unless they enroll in another HMO or CMP that is having an open 
enrollment. Beneficiaries who return to the fee-for-service system and 
apply for a Medigap policy could be subject to a waiting period of up 
to 6 months before preexisting conditions are covered. During the 
exclusion period, beneficiaries would have no coverage for payment of 
the coinsurance expenses, and possibly deductible expenses if the 
policy covered them, which are incurred as a result of preexisting 
conditions. The beneficiaries' only other alternative would be to 
purchase a policy with no waiting periods, if it were available, at a 
higher premium rate.
    Prior to the enactment of the Omnibus Budget Reconciliation Act of 
1987 (OBRA '87), Public Law 100-203, there was no statutory requirement 
that HMOs or CMPs terminating their contract with HCFA provide or 
arrange for terminated enrollees to obtain Medicare supplemental 
coverage without exclusion periods related to preexisting conditions. 
However, HCFA routinely requested that HMOs or CMPs arrange for such 
coverage, and all the HMOs or CMPs that terminated their contracts 
complied on a voluntary basis.

B. Legislation and Provisions of the Proposed Regulations

    In order to protect Medicare enrollees from loss of supplemental 
coverage for illness resulting from conditions existing prior to the 
termination of their HMO or CMP coverage, section 4011 of OBRA '87 
added section 1876(c)(3)(F) of the Act. Section 1876(c)(3)(F) states 
that each eligible organization that provides Medicare services under a 
contract must provide assurances to the Secretary that, in the event it 
ceases to provide such services, it will provide or arrange for 
supplemental coverage of Medicare benefits related to a preexisting 
condition with respect to any exclusion period, to all individuals 
enrolled with the entity who receive Medicare benefits for the lesser 
of 6 months or the duration of such period.
    We propose to follow the standards for preexisting condition 
exclusion clauses developed by the National Association of Insurance 
Commissioners (NAIC), and contained in the ``Model Regulation to 
Implement the NAIC Medicare Supplement Insurance Minimum Standards 
Model Act'' (the NAIC model). All States regulate Medicare supplement 
insurance (Medigap) policy packages according to the NAIC model (57 FR 
37487, August 21, 1992) standards which stipulate that preexisting 
condition exclusion clauses may be applied for a maximum of 6 months. 
This standard is consistent with the statutory requirement that the HMO 
or CMP provide supplemental exclusion coverage for a 6-month period, 
since the terminated enrollee may be precluded from obtaining such 
coverage when purchasing a Medigap policy on his or her own.
    The NAIC model currently describes ten standard Medigap policies, 
all of which include the following core benefits: Part A coinsurance, 
Part B coinsurance, 100 percent of Medicare Part A eligible 
hospitalization expenses for 365 hospital days in addition to Medicare 
standard and lifetime reserve days, and the cost of the first 3 pints 
of blood each year. The ten policies range in price and benefits from 
A, which includes just the core benefits, to plan J, which contains the 
most comprehensive package of benefits. At this time, only three of the 
NAIC standard policies--Plans C, F, and J--contain the benefits that 
are determined to meet our definition of supplemental exclusion 
coverage, a definition which is derived from the beneficiary cost-
sharing requirements for Part A and Part B as required under title 
XVIII. We define supplemental exclusion coverage to include the 
following benefits: The NAIC model core benefits as described above, 
Part A deductible, Part B deductible, and skilled nursing facility 
coinsurance.
    In order to implement section 1876(c)(3)(F) of the Act, we propose 
(Sec. 417.440(f)) to require that Medicare cost or risk-contracting 
HMOs or CMPs that cease to provide services are responsible for 
arranging supplemental coverage for a period of 6 months. This 
requirement would not apply when an HMO or CMP ceases to supply 
services to enrolled beneficiaries as a result of the beneficiaries' 
disenrollment under Secs. 417.460 (a) or (b). As described below and 
under proposed Sec. 417.440(f)(4), we propose to require the HMO or CMP 
to comply with one of the following supplemental coverage options:
    (1) Make available to eligible beneficiaries one or more Medigap 
policies without a preexisting condition waiting period; or at the 
State-approved rate for the same policy with a preexisting condition 
waiting period; or
    (2) Allow an eligible beneficiary to purchase a policy of his or 
her choice and--
    --Reimburse the beneficiary for all expenses related to a 
preexisting condition; or
    --Arrange for provision of services related to a preexisting 
condition without beneficiary cost-sharing.
    To exercise option one, we have determined that the most equitable 
standard for compliance with section 1876(c)(3)(F) is to require HMOs 
and CMPs with a Medicare contract that is terminated, not renewed, or 
renewed with a reduced service area, to offer former enrollees the 
least expensive NAIC model plan with benefits that meet the definition 
of supplemental exclusion coverage (plan C in most cases). Section 
1876(c)(3)(F) of the Act requires coverage for ``all individuals 
enrolled with the entity.'' Based on this language, we believe that 
Medicare enrollees who are under age 65 (that is, those eligible for 
Medicare because of disability or end stage renal disease) are intended 
to be covered by this regulation to the extent that a Medigap policy is 
available to them in the insurance marketplace. If a Medigap policy is 
not available, the proposed regulation would not apply, just as it 
would not apply to a Medicare enrollee over age 65 who chooses not to 
purchase a Medigap policy.
    We do not believe that the statute requires supplemental exclusion 
coverage to include all benefits that might have been provided by the 
HMO or CMP in excess of those benefits mandated and covered by 
Medicare. Examples of benefits that need not be included as 
supplemental exclusion coverage under this proposed rule would be 
``additional benefits'' or benefits not covered by Medicare but 
provided by the HMO or CMP for an additional payment by the enrollee, 
such as copayments for eyeglasses or hearing aids.
    ``Additional benefits'' are benefits that are provided by a risk 
HMO or CMP to its Medicare enrollees in accordance with Sec. 417.592 
which stipulates that, if an eligible organization's Adjusted Community 
Rate (ACR) for services to enrolled beneficiaries is less than the 
average per capita rate of payment it receives from Medicare, the 
entire difference must be accounted for. This must be accomplished 
either through HCFA's reducing the payments to the HMO or CMP, or by 
the HMO's or CMP's provision of additional benefits not covered by 
Medicare to all beneficiaries enrolled under the risk contract, at no 
additional charge. These ``additional benefits'' are calculated 
separately for those enrolled in both Part A and Part B, and for those 
enrolled in Part B only.
    Supplemental exclusion coverage would not apply to those 
beneficiaries who choose to enroll in another Medicare-contracting HMO 
or CMP because these organizations are not permitted to exclude 
preexisting conditions.
    Since section 1876(c)(3)(F) of the Act states that an HMO or CMP 
may either ``provide or arrange for'' supplemental coverage, we propose 
to permit an eligible organization to make available to terminated 
enrollees the following options to comply with this statute: (1) It may 
arrange with a Medigap insurer to make available for purchase by each 
eligible beneficiary the least expensive State-approved Medigap policy 
that includes the benefits defined as supplemental exclusion coverage. 
The policy must waive any preexisting condition exclusion clause, and 
must be made available to the beneficiary at a premium rate approved by 
the State insurance commissioner for the same policy with a preexisting 
condition exclusion. This does not impose a requirement on the Medigap 
insurer to discount a premium. However, an HMO or CMP that chooses this 
option must guarantee that the Medigap policy offered to the former 
enrollees covers any preexisting condition related services at the same 
premium as a comparable package of benefits with a preexisting 
condition exclusion clause. This provision is consistent with what we 
believe to be Congressional intent to provide certain former enrollees 
of Medicare risk HMOs and CMPs with access to Medigap policies that do 
not discriminate on the basis of benefit or price.
    (2) It may allow the former enrollee to purchase his or her own 
Medigap policy and--
     Reimburse the beneficiary for all of the Medicare 
deductible or coinsurance expenses for services that would have been 
covered by the Medigap policy but are not payable because of the 
existence of a preexisting condition exclusion clause; or
     Arrange for a physician or provider to furnish the actual 
services required as a result of the preexisting condition, with the 
HMO or CMP reimbursing the deductible and coinsurance amounts to the 
cooperating physician or provider on behalf of the former enrollee.
    Section 1876(c)(3)(F) of the Act does not specifically refer to 
reductions in service area. However, that section requires supplemental 
exclusion coverage ``in the event the organization ceases to provide * 
* * items and services'' under a Medicare contract. HCFA interprets 
this phrase to apply to beneficiaries who are disenrolled due to a 
contract termination or a reduction in the service area. The phrase 
does not apply to reduction in benefits as provided in Sec. 417.440 or 
to disenrollments under Secs. 417.460 (a) or (b).
    We considered permitting the HMO or CMP to satisfy this requirement 
by making available any State-approved Medigap policy, regardless of 
the benefit level. This option would give the HMO or CMP more 
flexibility in making arrangements for supplemental exclusion coverage 
and it would still provide the beneficiary with access to the Medigap 
market. However, since the NAIC model describes policies with several 
different levels of coverage, some conforming policies would not 
provide enrollees with coverage comparable to what they had with the 
HMO or CMP. We have decided to require the HMO or CMP to offer the 
least expensive policy that will comply with the supplemental exclusion 
coverage required under section 1876(c)(3)(F) of the Act. Additional 
policies may also be offered at a higher premium rate, as long as the 
policy includes the defined supplemental exclusion coverage benefits, 
at the State-approved premium rate for the same policy with a 
preexisting condition exclusion clause.
    In summary, we propose to amend Sec. 417.440(e) to require a risk 
or cost HMO or CMP whose contract with HCFA is terminated, not renewed, 
or renewed with a reduced service area, to offer affected Medicare 
enrollees who do not enroll in another Medicare contracting HMO or CMP, 
protection against out-of-pocket expenses because of a Medigap 
preexisting condition exclusion clause, in accordance with the 
requirements in proposed Sec. 417.440(f). Under proposed 
Sec. 417.440(f), we would require that the HMO or CMP provide at least 
one of the following options to former enrollees for the lesser of 6 
months after termination of enrollment or the duration of a Medigap 
insurance policy exclusion period:
     Make available for purchase by each former enrollee one or 
more State-approved Medicare supplement policies that waive the 
preexisting condition exclusion clause, at the premium rate approved by 
the State insurance commissioner for the same policy with such a 
clause. At least one of the policies must cover all of the expenses 
specified as supplemental exclusion coverage benefits at the lowest 
premium available in the area.
     Allow the former enrollee to obtain his or her own Medigap 
policy. If the policy imposes a preexisting condition exclusion clause, 
the HMO or CMP would be required to--
    --Reimburse the former enrollee for any benefits defined as 
supplemental exclusion coverage for services that would have been 
covered by the Medigap policy but for a preexisting condition exclusion 
clause; or
    --Arrange for a physician or provider to furnish the actual 
services related to the preexisting condition, with the HMO or CMP 
reimbursing the deductible and insurance amounts to the cooperating 
physician or provider on behalf of the former enrollee.
    We propose to add a new Sec. 417.541 to clarify that an HMO or CMP 
with a cost contract may not claim reimbursement for costs related to 
furnishing of the supplemental exclusion coverage required by the 
proposed Sec. 417.440(f).
    We also propose to revise Secs. 417.492 and 417.494 to require that 
an HMO or CMP whose contract with HCFA is terminated, not renewed, or 
modified with a reduced service area comply with Sec. 417.440(e) 
regarding the provision of supplemental exclusion coverage for their 
affected Medicare enrollees and Sec. 417.488 regarding the delivery of 
the appropriate notices to affected enrollees by risk HMOs or CMPs. In 
addition, we propose to revise Sec. 417.440(e) in order to clarify that 
inpatient hospital services would no longer be the only covered 
services that must be provided beyond the date of disenrollment. This 
rule would require that, under certain circumstances, supplemental 
exclusion coverage must be provided after the date of disenrollment. In 
addition, all covered hospital and medical expenses incurred before the 
date of termination must be paid by the HMO or CMP.

III. Immediate Open Enrollment for Risk HMOs or CMPs

A. Current Policy

    Before passage of the Omnibus Budget Reconciliation Act of 1989 
(OBRA '89), Public Law 101-239, there was no specific statutory 
requirement that a risk HMO or CMP that continued to operate in an area 
in which the contract of another risk HMO or CMP had been terminated, 
not renewed, or renewed with a reduced service area, enroll those 
Medicare beneficiaries who lost their prepaid health care coverage 
under the terminated contract. However, HCFA did require at 
Sec. 417.488 that the notice sent to enrollees advising them of their 
pending disenrollment, include a listing of other risk HMOs or CMPs 
operating in the service area. Also, there was no requirement that an 
HMO or CMP that continued to contract with HCFA hold an open enrollment 
at any time other than the annual 30-day period mandated by section 
1876(c)(A)(i) of the Act. Thus, Medicare beneficiaries who had been 
enrolled in the discontinued HMO or CMP had no alternative but to 
return to the fee-for-service payment system if no other HMO or CMP in 
the area was permitting new enrollment at the time of their 
termination.

B. Legislation

    Section 6206(b)(1)(B) of OBRA '89 amended section 1876(c)(3)(A)(ii) 
of the Act to require that if a risk contract is not renewed, is 
otherwise terminated, or is renewed with a reduced service area, a 
special open enrollment period for the terminated enrollees must be 
held by all other risk HMOs or CMPs operating in the same service area. 
This special open enrollment period must be for 30 days and must begin 
30 days after the date on which HCFA mails notice to the affected risk 
HMOs or CMPs informing them of their responsibility under section 
1876(c)(3)(A)(ii) of the Act. This period is only required to be open 
to those individuals enrolled under the terminated contract as of the 
date of termination.
    If the special open enrollment period coincides with the annual 
open enrollment period, the applications of all Medicare beneficiaries 
will be accepted in the order of application. We have considered giving 
precedence to the enrollees affected by the termination over new 
Medicare beneficiary applicants in cases where the enrollment periods 
do coincide. However, section 1876(c)(3)(A)(i) of the Act prohibits the 
HMO or CMP from restricting eligible beneficiaries' enrollment during 
open enrollment periods and we do not believe that section 
1876(c)(3)(A)(ii) allows us to waive this requirement. The special open 
enrollment period must be conducted in accordance with all of the 
requirements of Sec. 417.426, applicable to annual open enrollments. 
Enrollment becomes effective 30 days after the end of the special open 
enrollment period, or if HCFA determines that such a date is not 
feasible, such other date as HCFA specifies.

C. Provisions of This Proposed Rule

    Based on the provisions of section 1876(c)(3)(A)(ii) of the Act, as 
amended by section 6206 of OBRA '89, we are proposing to add a new 
Sec. 417.426(d) to provide that:
     HMOs or CMPs with risk contracts that serve a part of the 
same service area as an HMO or CMP whose risk contract is terminated, 
not renewed, or renewed with a reduced service area, for any reason, 
must provide a special open enrollment period for individuals enrolled 
under the terminated or revised contract.
     The special open enrollment period would be 30 days in 
duration and would begin 30 days after the date on which HCFA mails 
notice to the affected HMOs or CMPs informing them of their 
responsibility to hold a special open enrollment period.
     Coverage would become effective 30 days after the end of 
the special open enrollment period unless HCFA specifies a different 
effective date.
     This special open enrollment period may be in addition to, 
or coincide with, any annual open enrollment which the HMO or CMP is 
required to hold under Sec. 417.426.
     The special open enrollment period must comply with the 
requirements of Sec. 417.426.
    We are also proposing to amend Sec. 417.488 to require that, upon 
termination, nonrenewal, or reduction in the service area of a risk 
contract with HCFA, the HMO or CMP must provide to all of its former 
Medicare enrollees a list of the other risk HMOs and CMPs that are 
still operating in the service area, and a description of the special 
open enrollment period.

IV. Documentation of Enrollment for Medicare Enrollees of HMOs, 
CMPs, and HCPPs

A. Current Policy

    Section 1876(c)(3)(C) of the Act provides that the Secretary may 
prescribe the procedures and conditions under which an HMO or CMP may 
inform eligible Medicare beneficiaries about the organization, or may 
enroll those beneficiaries. Under Sec. 417.422(a)(4), each Medicare 
beneficiary requesting enrollment is required to complete an enrollment 
application form. Under Sec. 417.430(a)(1), this form must contain the 
beneficiary's signature, an authorization for disclosure and exchange 
of information between HCFA and the HMO or CMP and must comply with 
HCFA instructions regarding format and content. For risk HMOs and CMPs, 
the application form must include a notice explaining that the 
applicant may only obtain services from within the health care delivery 
system of the organization, except for emergency care or urgent care 
out of the service area. This notice must contain a statement detailing 
the enrollee's liability for non-covered services and for out-of-plan 
services when not authorized by a physician or official of the risk HMO 
or CMP.
    Current regulations at Sec. 417.430 prescribe the application 
processing requirements, including a requirement at Sec. 417.430(b)(3) 
that the HMO or CMP promptly notify an applicant of acceptance or 
denial of an application. However, there is no requirement that an HMO 
or CMP furnish to the applicant a copy of the enrollment application 
form, signed by the beneficiary and a representative of the HMO or CMP, 
at the time that the application is taken. Because there is generally a 
30-day lag time between the date on which the beneficiary files an 
application and the date that the HMO or CMP sends the notification of 
enrollment (which contains the rules that enrollees must follow), many 
Medicare enrollees are not fully informed of the requirements of the 
plan, especially the limitations on out of plan services. Moreover, our 
experience in the administration of the prepaid health care programs 
has demonstrated that a certain number of Medicare beneficiaries do not 
fully understand the restrictions that apply to enrollment in an HMO or 
CMP. As a result, they may continue to obtain services after the 
effective date of their enrollment from sources outside the HMO or CMP 
and then find that they are liable for payment for these services. 
Therefore, we believe that reinforcement of the rules and obligations 
inherent in an HMO or CMP enrollment is appropriate.
    It has been our policy to recommend that an HMO or CMP give a 
signed copy of the enrollment application to Medicare beneficiaries who 
apply for enrollment. However, this has been merely a recommendation 
and voluntary compliance has been sporadic. Because some Medicare 
beneficiaries may have difficulty fully understanding the HMO's or the 
CMP's rules and procedures, we believe that the enrollment application 
form should be presented to the enrollee on a mandatory basis, 
immediately after the actual signing. We believe that this additional 
step would strengthen our current enrollment procedures and 
significantly lower the number of disenrollments resulting from 
misunderstandings by enrollees. In addition, the presentation of the 
signed application form would also provide the prospective enrollee 
with in-hand documentation of intent to enroll in the HMO or CMP.
    There are no current regulations governing application procedures 
for enrollment in an HCPP. Thus, a Medicare beneficiary's application 
for membership might not be accepted in the order of application, or 
the beneficiary may never be notified in writing of the acceptance or 
denial of the application. In order to prevent potential problems, we 
are proposing to require HCPPs to utilize the same enrollment 
application procedures that HMOs and CMPs utilize.
    Since HCPPs are similar in organization to HMOs and the payment 
basis specified in the Act for HCPPs and cost-based HMOs is similar, we 
believe it would be appropriate to apply to HCPPs the same application 
procedures required for enrollment in cost-based HMOs. This proposed 
change would increase the uniformity of the application format and 
procedures for HCPPs and ensure that HCPPs have an effective system for 
receiving and processing applications from Medicare beneficiaries.

B. Provisions of This Proposed Rule

    We propose to amend Sec. 417.430 by adding a provision that would 
require each HMO or CMP to provide Medicare enrollees with a copy of 
the application form signed by the applicant and a representative of 
the HMO or CMP at the time the form is taken. In cases where the 
applicant submits the application by mail, the plan must furnish a copy 
to the applicant within 5 working days of receipt. In addition, we 
propose to amend Sec. 417.801 to require that HCPPs comply with the 
requirements of Sec. 417.430, that is, meet the same enrollment 
application procedures as contracting HMOs and CMPs. These procedures--
      Specify that a contracting HMO or CMP must comply with 
HCFA instructions concerning content of application forms;
     Require that a contracting HMO or CMP have an effective 
system for receiving, controlling and processing applications from 
Medicare beneficiaries; and
     Prescribe the details of an effective system for handling 
applications.

V. Adjusted Community Rate Proposal

A. Current Policy

    Section 1876(a)(1)(A) of the Act requires that HCFA provide risk 
HMOs or CMPs with the per capita rates of payment for each class of 
Medicare enrollees no later than September 7 before the calendar year 
in which the rates take effect. Regulations at Secs. 417.590 through 
417.598 specify how eligible organizations use the HCFA payment rates 
in determining their new premium rates and benefits for the coming 
year. Section 417.592(d)(1) requires that an HMO or CMP provide HCFA 
with this rate and benefit information not later than 45 days before 
the beginning of its contract period. The package of materials that an 
organization submits is called the Adjusted Community Rate Proposal. 
HMOs or CMPs generally wait until November 15 (the current deadline) to 
submit their adjusted community rates (ACRs) after receiving the per 
capita rates from HCFA. This effectively leaves 45 days for HCFA to 
review and approve, or disapprove, the ACRs from all risk HMOs or CMPs 
that contract with the agency. In November and December of 1986, 1987, 
1988, and 1989, HCFA accountants reviewed 139, 133, 135, and 107 ACRs, 
respectively, within the 45-day period.
    The review process involves the actuarial examination of proposed 
payment rates, which is a complex, time consuming operation. Over time, 
HCFA has found the 45-day period to be insufficient for allowing agency 
personnel to perform a thorough and adequate review of ACRs and to 
carry out necessary followup activities. For example, most ACRs contain 
errors. HCFA staff must detect these errors and contact the HMO or CMP 
to resolve the errors. Often HCFA requests that the HMO or CMP submit 
additional materials for review. In addition, program growth (in total 
number of Medicare beneficiaries served), and maturation of the 
coordinated care industry has led to the development of more 
sophisticated ACRs, resulting in the need to devote additional time to 
the review of plan materials.
    Following the review and approval by HCFA of an organization's ACR, 
the HMO or CMP must inform current enrollees of the new benefit package 
and rate changes for the coming contract year. This enrollee 
notification must occur 30 days before the effective date of the 
change. If the ACR has not been approved 30 days before the effective 
date, HCFA may allow the HMO or CMP to advertise the new benefit 
package. However, the advertisement must indicate that the announced 
rates are subject to approval by HCFA.

B. Provision of This Proposed Rule

    We propose to revise Sec. 417.592(d)(1) to require that each risk 
HMO or CMP submit its proposed ACR at least 60 days prior to the 
beginning of a contract period. This change would provide HCFA with an 
additional 15 days to review and approve or disapprove the proposed 
ACRs.
    A change in the deadline for submission of proposed ACRs from 45 to 
60 days before the beginning of a contract period would allow HCFA 
additional time to evaluate the ACRs, particularly in cases in which 
HCFA requests that the HMO or CMP provide supplemental documentation. 
The additional time also would permit a more thorough review of the 
proposals, reducing the potential for review errors. Making the 
deadline for submission of ACR proposals earlier would also help to 
ensure that enrollees have adequate notification of any contract 
changes in a timely manner.

VI. Response to Public Comments

    Because of the large number of items of correspondence we normally 
receive on a proposed rule, we are not able to acknowledge or respond 
to them individually. However, we will consider all comments that we 
receive by the date and time specified in the Dates section of this 
preamble, and we will respond to the comments in the preamble of the 
final rule that is issued.

VII. Regulatory Impact Statement

    We generally prepare a regulatory flexibility analysis that is 
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601 
through 612) unless the Secretary certifies that a proposed rule would 
not have a significant economic impact on a substantial number of small 
entities.
    The RFA defines ``small entity'' as a small business, a nonprofit 
enterprise, or a governmental jurisdiction (such as a county, city, or 
township) with a population of less than 50,000. We consider all HMOs, 
CMPs, and HCPPs to be small entities.
    Also, section 1102(b) of the Act requires the Secretary to prepare 
a regulatory impact analysis if a proposed rule may have a significant 
impact on the operations of a substantial number of small rural 
hospitals. Such an analysis must conform to the provisions of section 
604 of the RFA. For purposes of section 1102(b) of the Act, we define a 
small rural hospital as a hospital that is located outside of a 
Metropolitan Statistical Area and has fewer than 50 beds.
    There are currently 98 HMOs and CMPs that contract with HCFA to 
provide services on a risk basis to Medicare beneficiaries. Only 3 
percent of all Medicare beneficiaries are enrolled under these risk 
contracting plans. During the last fiscal year, eight risk-contracting 
HMOs and/or CMPs ceased providing services to beneficiaries on a risk 
basis. According to these data, the number of impacted small entities 
is very low.
    We have determined and the Secretary certifies that this proposed 
rule will not have a significant effect on a substantial number of 
small entities. Therefore, a regulatory flexibility analysis under the 
RFA and a rural impact analysis under section 1102(b) of the Act are 
not required.
    In accordance with the provisions of Executive Order 12866, this 
proposed rule was not reviewed by the Office of Management and Budget.

VIII. Information Collection Requirements

    Section 417.430 of this proposed rule contains information 
collection requirements that are subject to review by the Office of 
Management and Budget (OMB) under the Paperwork Reduction Act of 1980 
(44 U.S.C. 3501 et seq.).
    We have submitted this rule to the OMB for review. The information 
collection requirements concern personal information supplied by 
Medicare beneficiaries who are applying for membership in HCPPs. Public 
reporting burden for this collection of information is estimated to be 
\1/2\ hour per application. A notice will be published in the Federal 
Register when approval is obtained.

List of Subjects in 42 CFR Part 417

    Administrative practice and procedures, Health maintenance 
organizations (HMO), Medicare, Reporting and recordkeeping 
requirements.

    42 CFR part 417 would be amended as set forth below:

PART 417--HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL 
PLANS, AND HEALTH CARE PREPAYMENT PLANS

    1. The authority citation for part 417 continues to read as 
follows:

    Authority: Secs. 1102, 1833(a)(1)(A), 1861(s)(2)(H), 1866(a), 
1871, 1874, and 1876 of the Social Security Act (42 U.S.C. 1302, 
13951(a)(1)(A), 1395x(s)(2)(H), 1395cc(a), 1395hh, 1395kk, and 
1395mm); sec. 114(c) of Pub. L. 972-248 (42 U.S.C. 1395mm note); 31 
U.S.C. 9701 and secs. 215 and 1301 through 1318 of the Public Health 
Service Act (42 U.S.C. 216 and 300e through 300e-17), unless 
otherwise noted.

    2. Section 417.426 is amended by adding a new paragraph (d) to read 
as follows:


Sec. 417.426  Open enrollment requirements.

* * * * *
    (d) Special open enrollment. (1) If an HMO's or a CMP's risk 
contract is terminated, not renewed, or renewed with a reduced service 
area, all other HMOs or CMPs with risk contracts operating in the same 
service area must hold a special open enrollment period for the benefit 
of those Medicare enrollees whose enrollment in the HMO or CMP ends 
when the contract is terminated or modified.
    (2) The special open enrollment period must be 30 days in duration 
and begin 30 days after the date on which HCFA mails notice to the 
affected HMOs or CMPs, informing them of their responsibility under 
this section.
    (3) Enrollment is effective 30 days after the end of the special 
enrollment period or, if HCFA determines that date is not feasible, 
some other date that HCFA specifies.
    (4) The special open enrollment period is in addition to, unless it 
coincides with, the annual open enrollment period required under 
paragraph (a) of this section.
    (5) The special open enrollment period must be held in accordance 
with all of the requirements applicable to annual open enrollments 
under paragraphs (a) through (c) of this section.
    3. In Sec. 417.430, the introductory text of paragraph (b), and 
paragraph (b)(3) are revised to read as follows:


Sec. 417.430  Application procedures.

* * * * *
    (b) Handling of applications. An HMO or CMP must have an effective 
system for receiving, controlling, and processing applications from 
Medicare beneficiaries. The system must meet the following conditions 
and requirements:
* * * * *
    (3) The HMO or CMP--
    (i) Provides the applicant with a copy of the enrollment 
application form signed by the applicant and a representative of the 
HMO or CMP either when the application is taken, or, if the application 
is submitted by mail, within 5 working days of receipt; and
    (ii) Gives the beneficiary prompt written notice of acceptance or 
denial of the application.
* * * * *
    4. In Sec. 417.440, the section heading and paragraph (e) are 
revised, and a new paragraph (f) is added to read as follows:


Sec. 417.440  Entitlement to health care services from an HMO or CMP.

* * * * *
    (e) Financial responsibilities of an HMO or CMP after the effective 
date of disenrollment of a Medicare enrollee--(1) Inpatient hospital 
care. If a Medicare beneficiary's effective date of disenrollment 
occurs during an inpatient stay in a hospital paid under part 412 of 
this chapter and the HMO or CMP is financially responsible for the 
hospitalization, either because it arranged for the stay or, as 
provided under paragraph (a)(2) of this section, the financial 
responsibility for inpatient services continues through the date the 
beneficiary is discharged from the inpatient stay
    (2) Payment of outstanding bills. The HMO or CMP must pay for 
services furnished before the effective date of the contract 
termination or modification if the HMO or CMP would have been 
financially responsible for those services under the Medicare contract.
    (3) Protection against preexisting condition exclusions in Medicare 
supplement policies. For beneficiaries who are disenrolled because the 
Medicare contract is terminated or renewed with a reduced service area, 
the HMO or CMP must comply with the requirements of paragraph (f) of 
this section.
    (f) Supplemental exclusion coverage--(1) Definition. For the 
purposes of this section, supplemental exclusion coverage means payment 
for certain expenses incurred by a beneficiary for health care services 
related to a condition that exists at the time the beneficiary is 
disenrolled from a Medicare-contracting HMO or CMP according to 
paragraphs (f)(2) and (f)(3) of this section. Expenses included in 
supplemental exclusion coverage are Part A and Part B deductibles and 
coinsurance, SNF coinsurance, 100 percent of Medicare eligible Part A 
hospitalization expenses for 365 lifetime days after all Medicare 
hospital days (including lifetime reserve days) have been exhausted, 
and the annual cost of three pints of blood.
    (2) Basic rule. An HMO or CMP that ceases to provide health care 
services under a Medicare contract, or reduces its service area, must 
provide or arrange for supplemental exclusion coverage for any Medicare 
enrollee who--
    (i) Is disenrolled as a result of the cessation of services;
    (ii) Does not enroll in another Medicare-contracting HMO or CMP; 
and
    (iii) Would become liable for Medicare deductibles and coinsurance 
because he or she is unable to purchase a Medicare supplement policy 
without a waiting period for preexisting conditions.
    (3) Duration of coverage. Supplemental exclusion coverage must 
extend for 6 months after the termination or modification of the 
contract, or for the duration of any preexisting condition exclusion 
period imposed by the Medicare supplement policy, whichever is less.
    (4) Methods of providing supplemental exclusion coverage. To 
fulfill the supplemental exclusion coverage required under paragraph 
(f)(2) of this section, an HMO or CMP must select at least one of the 
following options: (i) Make available for purchase by each of its 
terminated Medicare enrollees, one or more State-approved Medicare 
supplement insurance policies that waive the preexisting condition 
exclusion clause, at the premium rate approved by the State Insurance 
Commissioner for the same policy with a preexisting condition exclusion 
clause. At least one of these policies must cover all of the expenses 
specified in Sec. 417.440(f)(1) of this section, at the lowest premium 
available in the area.
    (ii) Allow each former Medicare enrollee to purchase the Medicare 
supplement policy of his or her choice and, if that policy includes a 
preexisting condition exclusion clause, provide protection through 
either of the following:
    (A) Reimburse the former enrollee for all Medicare deductible and 
coinsurance expenses that are required to be paid under supplemental 
exclusion coverage as specified in paragraph (f)(1) of this section 
that are not payable by the Medicare supplement policy because of a 
preexisting condition exclusion clause.
    (B) Arrange for a physician or provider to furnish the services 
required as a result of the preexisting condition. The HMO or CMP must 
reimburse all deductible and coinsurance expenses identified as 
supplemental exclusion coverage and incurred for services provided in 
accordance with Sec. 417.440(e)(3) to the cooperating physician or 
provider on behalf of the former enrollee.
    5. In Sec. 417.488, the introductory text is revised; and new 
paragraphs (c) and (d) are added to read as follows:


Sec. 417.488  Written notice of termination.

    A risk contract must provide that if, for any reason, the contract 
is terminated, not renewed, or renewed with a reduced service area, the 
HMO or CMP agrees to provide to its affected Medicare enrollees, and to 
be responsible for the cost of, the following notices:
* * * * *
    (c) A list of all HMOs or CMPs with risk contracts that operate in 
the same service area and that must hold a special open enrollment for 
the affected Medicare enrollees, as required by Sec. 417.426(d).
    (d) A description of the special open enrollment process.
    6. In Sec. 417.492, a new paragraph (c) is added to read as 
follows:


Sec. 417.492  Nonrenewal of contract.

* * * * *
    (c) Supplemental exclusion coverage after nonrenewal by either HCFA 
or the HMO or CMP. If either HCFA or an HMO or CMP decides, for any 
reason, not to renew the contract, the HMO or CMP must provide 
supplemental exclusion coverage, as required under Sec. 417.440(f) for 
each Medicare enrollee whose coverage with the HMO or CMP will 
terminate. In addition, each HMO or CMP with a risk contract must 
provide the written notices required under Sec. 417.488.
    7. In Sec. 417.494, a new paragraph (d) is added to read as 
follows:


Sec. 417.494  Modification or termination of contract.

* * * * *
    (d) Supplemental exclusion coverage after modification or 
termination by either HCFA or the HMO or CMP. If either HCFA or an HMO 
or CMP, for any reason, terminates the contract or modifies it in such 
a manner that the service area is reduced, the HMO or CMP must provide 
supplemental exclusion coverage as required under Sec. 417.440(f) for 
each Medicare enrollee whose coverage with the HMO or CMP will 
terminate. In addition, each HMO or CMP with a risk contract must 
provide the written notices required under Sec. 417.488.
    8. A new Sec. 417.541 is added to read as follows:


Sec. 417.541  Supplemental exclusion coverage costs.

    Costs incurred by an organization for furnishing the supplemental 
exclusion coverage as required by Sec. 417.440(f) are not allowable.
    9. In Sec. 417.592, paragraph (d)(1) is revised to read as follows:


Sec. 417.592  Determination of required additional benefits.

* * * * *
    (d) Notification to HCFA. (1) The HMO or CMP must notify HCFA, not 
later than 60 days before the beginning of the contract period, of its 
ACR and its weighted average of its per capita rates of payment (as 
computed under Sec. 417.590) for the contract period.
* * * * *
    10. In Sec. 417.801, the introductory text of paragraph (b) is 
republished; paragraph (b)(6) is redesignated as paragraph (b)(7); and 
a new paragraph (b)(6) is added to read as follows:


Sec. 417.801  Agreements between HCFA and health care prepayment plans.

* * * * *
    (b) Terms. The agreement must provide that the HCPP agrees to--
* * * * *
    (6) Comply with the application procedures set forth in 
Sec. 417.430.
* * * * *
(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: June 2, 1993.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.

    Dated: November 9, 1993.
Donna E. Shalala,
Secretary.
[FR Doc. 94-5327 Filed 3-9-94; 8:45 am]
BILLING CODE 4120-01-P