S 2905 — Strengthening Partnerships to Prevent Opioid Abuse Act of 2018

(a) In general The Secretary shall not permit the election under section 1395w–21 of this title of a Medicare+Choice plan offered by a Medicare+Choice organization under this part, and no payment shall be made under section 1395w–23 of this title to an organization, unless the Secretary has entered into a contract under this section with the organization with respect to the offering of such plan. Such a contract with an organization may cover more than 1 Medicare+Choice plan. Such contract shall provide that the organization agrees to comply with the applicable requirements and standards of this part and the terms and conditions of payment as provided for in this part. (b) Minimum enrollment requirements (1) In general Subject to paragraph (2), the Secretary may not enter into a contract under this section with a Medicare+Choice organization unless the organization has— (A) at least 5,000 individuals (or 1,500 individuals in the case of an organization that is a provider-sponsored organization) who are receiving health benefits through the organization, or (B) at least 1,500 individuals (or 500 individuals in the case of an organization that is a provider-sponsored organization) who are receiving health benefits through the organization if the organization primarily serves individuals residing outside of urbanized areas. (2) Application to MSA plans In applying paragraph (1) in the case of a Medicare+Choice organization that is offering an MSA plan, paragraph (1) shall be applied by substituting covered lives for individuals. (3) Allowing transition The Secretary may waive the requirement of paragraph (1) during the first 3 contract years with respect to an organization. (c) Contract period and effectiveness (1) Period Each contract under this section shall be for a term of at least 1 year, as determined by the Secretary, and may be made automatically renewable from term to term in the absence of notice by either party of intention to terminate at the end of the current term. (2) Termination authority In accordance with procedures established under subsection (h), the Secretary may at any time terminate any such contract if the Secretary determines that the organization— (A) has failed substantially to carry out the contract; (B) is carrying out the contract in a manner inconsistent with the efficient and effective administration of this part; or (C) no longer substantially meets the applicable conditions of this part. (3) Effective date of contracts The effective date of any contract executed pursuant to this section shall be specified in the contract, except that in no case shall a contract under this section which provides for coverage under an MSA plan be effective before January 1999 with respect to such coverage. (4) Previous terminations (A) In general The Secretary may not enter into a contract with a Medicare+Choice organization if a previous contract with that organization under this section was terminated at the request of the organization within the preceding 2-year period, except as provided in subparagraph (B) and except in such other circumstances which warrant special consideration, as determined by the Secretary. (B) Earlier re-entry permitted where change in payment policy Subparagraph (A) shall not apply with respect to the offering by a Medicare+Choice organization of a Medicare+Choice plan in a Medicare+Choice payment area if during the 6-month period beginning on the date the organization notified the Secretary of the intention to terminate the most recent previous contract, there was a legislative change enacted (or a regulatory change adopted) that has the effect of increasing payment amounts under section 1395w–23 of this title for that Medicare+Choice payment area. (5) Contracting authority The authority vested in the Secretary by this part may be performed without regard to such provisions of law or regulations relating to the making, performance, amendment, or modification of contracts of the Uni...

(a) Definitions relating to Medicare+Choice organizations In this part— (1) Medicare+Choice organization The term “Medicare+Choice organization” means a public or private entity that is certified under section 1395w–26 of this title as meeting the requirements and standards of this part for such an organization. (2) Provider-sponsored organization The term “provider-sponsored organization” is defined in section 1395w–25(d)(1) of this title. (b) Definitions relating to Medicare+Choice plans (1) Medicare+Choice plan The term “Medicare+Choice plan” means health benefits coverage offered under a policy, contract, or plan by a Medicare+Choice organization pursuant to and in accordance with a contract under section 1395w–27 of this title. (2) Medicare+Choice private fee-for-service plan The term “Medicare+Choice private fee-for-service plan” means a Medicare+Choice plan that— (A) reimburses hospitals, physicians, and other providers at a rate determined by the plan on a fee-for-service basis without placing the provider at financial risk; (B) does not vary such rates for such a provider based on utilization relating to such provider; and (C) does not restrict the selection of providers among those who are lawfully authorized to provide the covered services and agree to accept the terms and conditions of payment established by the plan. Nothing in subparagraph (B) shall be construed to preclude a plan from varying rates for such a provider based on the specialty of the provider, the location of the provider, or other factors related to such provider that are not related to utilization, or to preclude a plan from increasing rates for such a provider based on increased utilization of specified preventive or screening services. (3) MSA plan (A) In general The term “MSA plan” means a Medicare+ÐChoice plan that— (i) provides reimbursement for at least the items and services described in section 1395w–22(a)(1) of this title in a year but only after the enrollee incurs countable expenses (as specified under the plan) equal to the amount of an annual deductible (described in subparagraph (B)); (ii) counts as such expenses (for purposes of such deductible) at least all amounts that would have been payable under parts A and B, and that would have been payable by the enrollee as deductibles, coinsurance, or copayments, if the enrollee had elected to receive benefits through the provisions of such parts; and (iii) provides, after such deductible is met for a year and for all subsequent expenses for items and services referred to in clause (i) in the year, for a level of reimbursement that is not less than— (I) 100 percent of such expenses, or (II) 100 percent of the amounts that would have been paid (without regard to any deductibles or coinsurance) under parts A and B with respect to such expenses,  whichever is less. (B) Deductible The amount of annual deductible under an MSA plan— (i) for contract year 1999 shall be not more than $6,000; and (ii) for a subsequent contract year shall be not more than the maximum amount of such deductible for the previous contract year under this subparagraph increased by the national per capita Medicare+Choice growth percentage under section 1395w–23(c)(6) of this title for the year. If the amount of the deductible under clause (ii) is not a multiple of $50, the amount shall be rounded to the nearest multiple of $50. (4) MA regional plan The term “MA regional plan” means an MA plan described in section 1395w–21(a)(2)(A)(i) of this title— (A) that has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (B) that provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and (C) the service area of which is one or more entire MA regions. (5) MA local plan The term “MA local plan” means an MA plan that is not an MA regional plan. (6) Specialized...