TITLE 42 - PUBLIC HEALTH

CHAPTER IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

SUBCHAPTER B - MEDICARE PROGRAM

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

subpart p - MEDICARE PAYMENT: RISK BASIS

417.592 - Additional benefits requirement.

  (a) General rules. (1) An HMO or CMP that has an APCRP (as determined under 417.590) greater than its ACR (as determined under 417.594) must elect one of the options specified in paragraph (b) of this section.

  (2) The dollar value of the elected option must, over the course of a contract period, be at least equal to the difference between the APCRP and the proposed ACR.

  (b) Options(1) Additional benefits. Provide its Medicare enrollees with additional benefits in accordance with paragraph (c) of this section.

  (2) Payment reduction. Request CMS to reduce its monthly payments.

  (3) Combination of additional benefits and payment reduction. Provide fewer than the additional benefits required under paragraph (b)(1) of this section and request CMS to reduce the monthly payments by the remaining difference between the APCRP and the ACR.

  (4) Combination of additional benefits and withholding in a stabilization fund. Provide fewer than the additional benefits required under paragraph (b)(1) of this section, and request CMS to withhold in a stabilization fund (as provided in 417.596) the remaining difference between the APCRP and the ACR.

  (c) Special rules: Additional benefits option. (1) The HMO or CMP must determine additional benefits separately for enrollees entitled to both Part A and Part B benefits and those entitled only to Part B.

  (2) The HMO or CMP may elect to provide additional benefits in any of the following forms (i) A reduction in the HMO's or CMP's premium or in other charges it imposes in the form of deductibles or coinsurance.

  (ii) Health benefits in addition to the required Part A and Part B covered services.

  (iii) A combination of reduced charges and additional benefits.

  (d) Notification to CMS. (1) The HMO or CMP must give CMS notice of its ACR and its weighted APCRP at least 45 days before its contract period begins.

  (2) An HMO or CMP that elects the option of providing additional benefits must include in its submittal (i) A description of the additional benefits it will provide to its Medicare enrollees; and (ii) Supporting evidence to show that the selected benefits meet the requirements of paragraph (a)(2) of this section with respect to dollar value equivalence.

[60 FR 46232, Sept. 6, 1995]