loading…
loading…
loading…
(1) In general
Each MA organization shall have an ongoing quality improvement program for the purpose of improving the quality of care provided to enrollees in each MA plan offered by such organization.
As part of the quality improvement program under paragraph (1), each MA organization shall have a chronic care improvement program. Each chronic care improvement program shall have a method for monitoring and identifying enrollees with multiple or sufficiently severe chronic conditions that meet criteria established by the organization for participation under the program.
(A) Collection, analysis, and reporting (i) In general Except as provided in clauses (ii) and (iii) with respect to plans described in such clauses and subject to subparagraph (B), as part of the quality improvement program under paragraph (1), each MA organization shall provide for the collection, analysis, and reporting of data that permits the measurement of health outcomes and other indices of quality. With respect to MA private fee-for-service plans and MSA plans, the requirements under the preceding sentence may not exceed the requirements under this subparagraph with respect to MA local plans that are preferred provider organization plans, except that, for plan year 2010, the limitation under clause (iii) shall not apply and such requirements shall apply only with respect to administrative claims data. (ii) Special requirements for specialized MA plans for special needs individuals In addition to the data required to be collected, analyzed, and reported under clause (i) and notwithstanding the limitations under subparagraph (B), as part of the quality improvement program under paragraph (1), each MA organization offering a specialized Medicare Advantage plan for special needs individuals shall provide for the collection, analysis, and reporting of data that permits the measurement of health outcomes and other indices of quality with respect to the requirements described in paragraphs (2) through (5) of subsection (f). Such data may be based on claims data and shall be at the plan level. (iii) Application to local preferred provider organizations and MA regional plans Clause (i) shall apply to MA organizations with respect to MA local plans that are preferred provider organization plans and to MA regional plans only insofar as services are furnished by providers or services, physicians, and other health care practitioners and suppliers that have contracts with such organization to furnish services under such plans. (iv) Definition of preferred provider organization plan In this subparagraph, the term “preferred provider organization plan” means an MA plan that— (I) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (II) provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and (III) is offered by an organization that is not licensed or organized under State law as a health maintenance organization.
(B) Limitations (i) Types of data The Secretary shall not collect under subparagraph (A) data on quality, outcomes, and beneficiary satisfaction to facilitate consumer choice and program administration other than the types of data that were collected by the Secretary as of November 1, 2003 . (ii) Changes in types of data Subject to subclause (iii), the Secretary may only change the types of data that are required to be submitted under subparagraph (A) after submitting to Congress a report on the reasons for such changes that was prepared in consultation with MA organizations and private accrediting bodies. (iii) Construction Nothing in the 2 2 So in original. Probably should be “this”. subsection shall be construed as restricting the ability of the Secretary to carry out the duties under section 1395w–21(d)(4)(D) of this title .
(i) In general Except as provided in clauses (ii) and (iii) with respect to plans described in such clauses and subject to subparagraph (B), as part of the quality improvement program under paragraph (1), each MA organization shall provide for the collection, analysis, and reporting of data that permits the measurement of health outcomes and other indices of quality. With respect to MA private fee-for-service plans and MSA plans, the requirements under the preceding sentence may not exceed the requirements under this subparagraph with respect to MA local plans that are preferred provider organization plans, except that, for plan year 2010, the limitation under clause (iii) shall not apply and such requirements shall apply only with respect to administrative claims data.
(ii) Special requirements for specialized MA plans for special needs individuals In addition to the data required to be collected, analyzed, and reported under clause (i) and notwithstanding the limitations under subparagraph (B), as part of the quality improvement program under paragraph (1), each MA organization offering a specialized Medicare Advantage plan for special needs individuals shall provide for the collection, analysis, and reporting of data that permits the measurement of health outcomes and other indices of quality with respect to the requirements described in paragraphs (2) through (5) of subsection (f). Such data may be based on claims data and shall be at the plan level.
(iii) Application to local preferred provider organizations and MA regional plans Clause (i) shall apply to MA organizations with respect to MA local plans that are preferred provider organization plans and to MA regional plans only insofar as services are furnished by providers or services, physicians, and other health care practitioners and suppliers that have contracts with such organization to furnish services under such plans.
(iv) Definition of preferred provider organization plan In this subparagraph, the term “preferred provider organization plan” means an MA plan that— (I) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (II) provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and (III) is offered by an organization that is not licensed or organized under State law as a health maintenance organization.
Except as provided in clauses (ii) and (iii) with respect to plans described in such clauses and subject to subparagraph (B), as part of the quality improvement program under paragraph (1), each MA organization shall provide for the collection, analysis, and reporting of data that permits the measurement of health outcomes and other indices of quality. With respect to MA private fee-for-service plans and MSA plans, the requirements under the preceding sentence may not exceed the requirements under this subparagraph with respect to MA local plans that are preferred provider organization plans, except that, for plan year 2010, the limitation under clause (iii) shall not apply and such requirements shall apply only with respect to administrative claims data.
In addition to the data required to be collected, analyzed, and reported under clause (i) and notwithstanding the limitations under subparagraph (B), as part of the quality improvement program under paragraph (1), each MA organization offering a specialized Medicare Advantage plan for special needs individuals shall provide for the collection, analysis, and reporting of data that permits the measurement of health outcomes and other indices of quality with respect to the requirements described in paragraphs (2) through (5) of subsection (f). Such data may be based on claims data and shall be at the plan level.
Clause (i) shall apply to MA organizations with respect to MA local plans that are preferred provider organization plans and to MA regional plans only insofar as services are furnished by providers or services, physicians, and other health care practitioners and suppliers that have contracts with such organization to furnish services under such plans.
In this subparagraph, the term “preferred provider organization plan” means an MA plan that—
(I) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan;
(II) provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and
(III) is offered by an organization that is not licensed or organized under State law as a health maintenance organization.
has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan;
provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and
is offered by an organization that is not licensed or organized under State law as a health maintenance organization.
(i) Types of data The Secretary shall not collect under subparagraph (A) data on quality, outcomes, and beneficiary satisfaction to facilitate consumer choice and program administration other than the types of data that were collected by the Secretary as of November 1, 2003 .
(ii) Changes in types of data Subject to subclause (iii), the Secretary may only change the types of data that are required to be submitted under subparagraph (A) after submitting to Congress a report on the reasons for such changes that was prepared in consultation with MA organizations and private accrediting bodies.
(iii) Construction Nothing in the 2 2 So in original. Probably should be “this”. subsection shall be construed as restricting the ability of the Secretary to carry out the duties under section 1395w–21(d)(4)(D) of this title .
The Secretary shall not collect under subparagraph (A) data on quality, outcomes, and beneficiary satisfaction to facilitate consumer choice and program administration other than the types of data that were collected by the Secretary as of November 1, 2003 .
Subject to subclause (iii), the Secretary may only change the types of data that are required to be submitted under subparagraph (A) after submitting to Congress a report on the reasons for such changes that was prepared in consultation with MA organizations and private accrediting bodies.
Nothing in the 2 2 So in original. Probably should be “this”. subsection shall be construed as restricting the ability of the Secretary to carry out the duties under section 1395w–21(d)(4)(D) of this title .
(A) In general The Secretary shall provide that a Medicare+Choice organization is deemed to meet all the requirements described in any specific clause of subparagraph (B) if the organization is accredited (and periodically reaccredited) by a private accrediting organization under a process that the Secretary has determined assures that the accrediting organization applies and enforces standards that meet or exceed the standards established under section 1395w–26 of this title to carry out the requirements in such clause.
(B) Requirements described The provisions described in this subparagraph are the following: (i) Paragraphs (1) through (3) of this subsection (relating to quality improvement programs). (ii) Subsection (b) (relating to antidiscrimination). (iii) Subsection (d) (relating to access to services). (iv) Subsection (h) (relating to confidentiality and accuracy of enrollee records). (v) Subsection (i) (relating to information on advance directives). (vi) Subsection (j) (relating to provider participation rules). (vii) The requirements described in section 1395w–104(j) of this title , to the extent such requirements apply under section 1395w–131(c) of this title .
(C) Timely action on applications The Secretary shall determine, within 210 days after the date the Secretary receives an application by a private accrediting organization and using the criteria specified in section 1395bb(a)(2) of this title , whether the process of the private accrediting organization meets the requirements with respect to any specific clause in subparagraph (B) with respect to which the application is made. The Secretary may not deny such an application on the basis that it seeks to meet the requirements with respect to only one, or more than one, such specific clause.
(D) Construction Nothing in this paragraph shall be construed as limiting the authority of the Secretary under section 1395w–27 of this title , including the authority to terminate contracts with Medicare+Choice organizations under subsection (c)(2) of such section.
The Secretary shall provide that a Medicare+Choice organization is deemed to meet all the requirements described in any specific clause of subparagraph (B) if the organization is accredited (and periodically reaccredited) by a private accrediting organization under a process that the Secretary has determined assures that the accrediting organization applies and enforces standards that meet or exceed the standards established under section 1395w–26 of this title to carry out the requirements in such clause.
The provisions described in this subparagraph are the following:
(i) Paragraphs (1) through (3) of this subsection (relating to quality improvement programs).
(ii) Subsection (b) (relating to antidiscrimination).
(iii) Subsection (d) (relating to access to services).
(iv) Subsection (h) (relating to confidentiality and accuracy of enrollee records).
(v) Subsection (i) (relating to information on advance directives).
(vi) Subsection (j) (relating to provider participation rules).
(vii) The requirements described in section 1395w–104(j) of this title , to the extent such requirements apply under section 1395w–131(c) of this title .
Paragraphs (1) through (3) of this subsection (relating to quality improvement programs).
Subsection (b) (relating to antidiscrimination).
Subsection (d) (relating to access to services).
Subsection (h) (relating to confidentiality and accuracy of enrollee records).
Subsection (i) (relating to information on advance directives).
Subsection (j) (relating to provider participation rules).
The requirements described in section 1395w–104(j) of this title , to the extent such requirements apply under section 1395w–131(c) of this title .
The Secretary shall determine, within 210 days after the date the Secretary receives an application by a private accrediting organization and using the criteria specified in section 1395bb(a)(2) of this title , whether the process of the private accrediting organization meets the requirements with respect to any specific clause in subparagraph (B) with respect to which the application is made. The Secretary may not deny such an application on the basis that it seeks to meet the requirements with respect to only one, or more than one, such specific clause.
Nothing in this paragraph shall be construed as limiting the authority of the Secretary under section 1395w–27 of this title , including the authority to terminate contracts with Medicare+Choice organizations under subsection (c)(2) of such section.