Page:United States Statutes at Large Volume 104 Part 2.djvu/517

From Wikisource
Jump to: navigation, search
This page needs to be proofread.

PUBLIC LAW 101-508—NOV. 5, 1990 104 STAT. 1388-109 reduce or limit medically necessary services provided with respect to a specific individual enrolled with the organization, "(ii) If the plan places a physician or physician group at substantial financial risk (as determined by the Secretary) for services not provided by the physician or physician group, the organization— "(I) provides stop-loss protection for the physician or group that is adequate and appropriate, based on standards developed by the Secretary that take into account the number of physicians placed at such substantial financial risk in the group or under the plan and the number of individuals enrolled with the organization who receive services from the physician or the physician group, and "(II) conducts periodic surveys of both individuals enrolled and individuals previously enrolled with the organization to determine the degree of access of such individuals to services provided by the organization and satisfaction with the quality of such services. "(iii) The organization provides the Secretary with descriptive information regarding the plan, sufficient to permit the Secretary to determine whether the plan is in compliance with the requirements of this subparagraph. "(B) In this paragraph, the term 'physician incentive plan' means any compensation arrangement between an eligible organization and a physician or physician group that may directly or indirectly have the effect of reducing or limiting services provided with respect to individuals enrolled with the organization.". (2) PENALTIES.— Section 1876(i)(6)(A)(vi) (42 U.S.C. 1395mm(i)(6)(A)(vi)) is amended by striking "(g)(6)(A);" and inserting "(g)(6)(A) or paragraph (8);". (3) REPEAL OF PROHIBITION. —Section 1128A(b)(l) (42 U.S.C. 1320a-7a(b)(l)) is amended— (A) by striking ", an eligible organization" and all that follows through "section 1876,", (B) by adding "and" at the end of subparagraph (A), (C) by striking subparagraph (B), (D) by redesignating subparagraph (C) as subparagraph (B), and (E) by striking "or organization". (4) EFFECTIVE DATE. — The amendments made by paragraphs (1) and (2) shall apply with respect to contract years beginning on or after January 1, 1992, and the amendments made by paragraph (3) shall take effect on the date of the enactment of this Act. (b) REQUIREMENTS WITH RESPECT TO ACTUARIAL EQUIVALENCE OF AAPCC—(1) Not later than January 1, 1992, the Secretary of Health and Human Services (in this section referred to as the "Secretary") shall submit a proposal to Congress that provides for a modified payment method for organizations with a risk contract under section 1876(g) of the Social Security Act that is more accurate than the current payment methodology in predicting the actual service utilization and annual medical expenditures of the beneficiary population enrolled in a specific organization. (2) The proposal shall include— (A)(i) recommendations on modifying the current adjusted average per capita cost formula, by adding predictors of medical 42 USC 1395mm note. 42 USC 1395mm note.