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§ 1395w–23. Payments to Medicare+Choice organizations
(a)
Payments to organizations
(1)
Monthly payments
(A)
In general
Under a contract under section
1395w–27 of this title and subject to subsections (e), (g), and (i) of this section and section
1395w–28
(e)(4) of this title, the Secretary shall make monthly payments under this section in advance to each Medicare+Choice organization, with respect to coverage of an individual under this part in a Medicare+Choice payment area for a month, in an amount determined as follows:
(i)
Payment before 2006
For years before 2006, the payment amount shall be equal to 1/12 of the annual MA capitation rate (as calculated under subsection (c)(1) of this section) with respect to that individual for that area, adjusted under subparagraph (C) and reduced by the amount of any reduction elected under section
1395w–24
(f)(1)(E) of this title.
(B)
Payment amount for original fee-for-service benefits beginning with 2006
(i)
Payment of bid for plans with bids below benchmark
In the case of a plan for which there are average per capita monthly savings described in section
1395w–24
(b)(3)(C) or
1395w–24
(b)(4)(C) of this title, as the case may be, the amount specified in this subparagraph is equal to the unadjusted MA statutory non-drug monthly bid amount, adjusted under subparagraph (C) and (if applicable) under subparagraphs (F) and (G), plus the amount (if any) of any rebate under subparagraph (E).
(ii)
Payment of benchmark for plans with bids at or above benchmark
In the case of a plan for which there are no average per capita monthly savings described in section
1395w–24
(b)(3)(C) or
1395w–24
(b)(4)(C) of this title, as the case may be, the amount specified in this subparagraph is equal to the MA area-specific non-drug monthly benchmark amount, adjusted under subparagraph (C) and (if applicable) under subparagraphs (F) and (G).
(C)
Demographic adjustment, including adjustment for health status
The Secretary shall adjust the payment amount under subparagraph (A)(i) and the amount specified under subparagraph (B)(i), (B)(ii), and (B)(iii) for such risk factors as age, disability status, gender, institutional status, and such other factors as the Secretary determines to be appropriate, including adjustment for health status under paragraph (3), so as to ensure actuarial equivalence. The Secretary may add to, modify, or substitute for such adjustment factors if such changes will improve the determination of actuarial equivalence.
(D)
Separate payment for Federal drug subsidies
In the case of an enrollee in an MA–PD plan, the MA organization offering such plan also receives—
(E)
Payment of rebate for plans with bids below benchmark
In the case of a plan for which there are average per capita monthly savings described in section
1395w–24
(b)(3)(C) or
1395w–24
(b)(4)(C) of this title, as the case may be, the amount specified in this subparagraph is the amount of the monthly rebate computed under section
1395w–24
(b)(1)(C)(i) of this title for that plan and year (as reduced by the amount of any credit provided under section
1395w–24
(b)(1)(C)(iv) of this title).
(F)
Adjustment for intra-area variations
(i)
Intra-regional variations
In the case of payment with respect to an MA regional plan for an MA region, the Secretary shall also adjust the amounts specified under subparagraphs (B)(i) and (B)(ii) in a manner to take into account variations in MA local payment rates under this part among the different MA local areas included in such region.
(ii)
Intra-service area variations
In the case of payment with respect to an MA local plan for a service area that covers more than one MA local area, the Secretary shall also adjust the amounts specified under subparagraphs (B)(i) and (B)(ii) in a manner to take into account variations in MA local payment rates under this part among the different MA local areas included in such service area.
(G)
Adjustment relating to risk adjustment
The Secretary shall adjust payments with respect to MA plans as necessary to ensure that—
(H)
Special rule for end-stage renal disease
The Secretary shall establish separate rates of payment to a Medicare+Choice organization with respect to classes of individuals determined to have end-stage renal disease and enrolled in a Medicare+Choice plan of the organization. Such rates of payment shall be actuarially equivalent to rates that would have been paid with respect to other enrollees in the MA payment area (or such other area as specified by the Secretary) under the provisions of this section as in effect before December 8, 2003. In accordance with regulations, the Secretary shall provide for the application of the seventh sentence of section
1395rr
(b)(7) of this title to payments under this section covering the provision of renal dialysis treatment in the same manner as such sentence applies to composite rate payments described in such sentence. In establishing such rates, the Secretary shall provide for appropriate adjustments to increase each rate to reflect the demonstration rate (including the risk adjustment methodology associated with such rate) of the social health maintenance organization end-stage renal disease capitation demonstrations (established by section 2355 of the Deficit Reduction Act of 1984, as amended by section 13567(b) of the Omnibus Budget Reconciliation Act of 1993), and shall compute such rates by taking into account such factors as renal treatment modality, age, and the underlying cause of the end-stage renal disease. The Secretary may apply the competitive bidding methodology provided for in this section, with appropriate adjustments to account for the risk adjustment methodology applied to end stage renal disease payments.
(2)
Adjustment to reflect number of enrollees
(A)
In general
The amount of payment under this subsection may be retroactively adjusted to take into account any difference between the actual number of individuals enrolled with an organization under this part and the number of such individuals estimated to be so enrolled in determining the amount of the advance payment.
(B)
Special rule for certain enrollees
(i)
In general
Subject to clause (ii), the Secretary may make retroactive adjustments under subparagraph (A) to take into account individuals enrolled during the period beginning on the date on which the individual enrolls with a Medicare+Choice organization under a plan operated, sponsored, or contributed to by the individual’s employer or former employer (or the employer or former employer of the individual’s spouse) and ending on the date on which the individual is enrolled in the organization under this part, except that for purposes of making such retroactive adjustments under this subparagraph, such period may not exceed 90 days.
(3)
Establishment of risk adjustment factors
(A)
Report
The Secretary shall develop, and submit to Congress by not later than March 1, 1999, a report on the method of risk adjustment of payment rates under this section, to be implemented under subparagraph (C), that accounts for variations in per capita costs based on health status. Such report shall include an evaluation of such method by an outside, independent actuary of the actuarial soundness of the proposal.
(B)
Data collection
In order to carry out this paragraph, the Secretary shall require Medicare+Choice organizations (and eligible organizations with risk-sharing contracts under section
1395mm of this title) to submit data regarding inpatient hospital services for periods beginning on or after July 1, 1997, and data regarding other services and other information as the Secretary deems necessary for periods beginning on or after July 1, 1998. The Secretary may not require an organization to submit such data before January 1, 1998.
(C)
Initial implementation
(i)
In general
The Secretary shall first provide for implementation of a risk adjustment methodology that accounts for variations in per capita costs based on health status and other demographic factors for payments by no later than January 1, 2000.
(ii)
Phase-in
Except as provided in clause (iv), such risk adjustment methodology shall be implemented in a phased-in manner so that the methodology insofar as it makes adjustments to capitation rates for health status applies to—
(iii)
Data for risk adjustment methodology
Such risk adjustment methodology for 2004 and each succeeding year, shall be based on data from inpatient hospital and ambulatory settings.
(iv)
Full implementation of risk adjustment for congestive heart failure enrollees for 2001
(I)
Exemption from phase-in
Subject to subclause (II), the Secretary shall fully implement the risk adjustment methodology described in clause (i) with respect to each individual who has had a qualifying congestive heart failure inpatient diagnosis (as determined by the Secretary under such risk adjustment methodology) during the period beginning on July 1, 1999, and ending on June 30, 2000, and who is enrolled in a coordinated care plan that is the only coordinated care plan offered on January 1, 2001, in the service area of the individual.
(4)
Payment rule for federally qualified health center services
If an individual who is enrolled with an MA plan under this part receives a service from a federally qualified health center that has a written agreement with the MA organization that offers such plan for providing such a service (including any agreement required under section
1395w–27
(e)(3) of this title)—
(b)
Annual announcement of payment rates
(1)
Annual announcements
(A)
For 2005
The Secretary shall determine, and shall announce (in a manner intended to provide notice to interested parties), not later than the second Monday in May of 2004, with respect to each MA payment area, the following:
(B)
For 2006 and subsequent years
For a year after 2005—
(i)
Initial announcement
The Secretary shall determine, and shall announce (in a manner intended to provide notice to interested parties), not later than the first Monday in April before the calendar year concerned, with respect to each MA payment area, the following:
(ii)
Regional benchmark announcement
The Secretary shall determine, and shall announce (in a manner intended to provide notice to interested parties), on a timely basis before the calendar year concerned, with respect to each MA region and each MA regional plan for which a bid was submitted under section
1395w–24 of this title, the MA region-specific non-drug monthly benchmark amount for that region for the year involved.
(iii)
Benchmark announcement for CCA local areas
The Secretary shall determine, and shall announce (in a manner intended to provide notice to interested parties), on a timely basis before the calendar year concerned, with respect to each CCA area (as defined in section
1395w–29
(b)(1)(A) of this title), the CCA non-drug monthly benchmark amount under section
1395w–29
(e)(1) of this title for that area for the year involved.
(2)
Advance notice of methodological changes
At least 45 days before making the announcement under paragraph (1) for a year, the Secretary shall provide for notice to Medicare+Choice organizations of proposed changes to be made in the methodology from the methodology and assumptions used in the previous announcement and shall provide such organizations an opportunity to comment on such proposed changes.
(3)
Explanation of assumptions
In each announcement made under paragraph (1), the Secretary shall include an explanation of the assumptions and changes in methodology used in such announcement.
(4)
Continued computation and publication of county-specific per capita fee-for-service expenditure information
The Secretary, through the Chief Actuary of the Centers for Medicare & Medicaid Services, shall provide for the computation and publication, on an annual basis beginning with 2001 at the time of publication of the annual Medicare+Choice capitation rates under paragraph (1), of the following information for the original medicare fee-for-service program under parts A and B of this subchapter (exclusive of individuals eligible for coverage under section
426–1 of this title) for each Medicare+Choice payment area for the second calendar year ending before the date of publication:
(A)
Total expenditures per capita per month, computed separately for part A of this subchapter and for part B of this subchapter.
(B)
The expenditures described in subparagraph (A) reduced by the best estimate of the expenditures (such as graduate medical education and disproportionate share hospital payments) not related to the payment of claims.
(c)
Calculation of annual Medicare+Choice capitation rates
(1)
In general
For purposes of this part, subject to paragraphs (6)(C) and (7), each annual Medicare+Choice capitation rate, for a Medicare+Choice payment area that is an MA local area for a contract year consisting of a calendar year, is equal to the largest of the amounts specified in the following subparagraph (A), (B), (C), or (D):
(A)
Blended capitation rate
For a year before 2005, the sum of—
(i)
the area-specific percentage (as specified under paragraph (2) for the year) of the annual area-specific Medicare+Choice capitation rate for the Medicare+Choice payment area, as determined under paragraph (3) for the year, and
(ii)
the national percentage (as specified under paragraph (2) for the year) of the input-price-adjusted annual national Medicare+Choice capitation rate, as determined under paragraph (4) for the year,
multiplied (for a year other than 2004) by the budget neutrality adjustment factor determined under paragraph (5).
(B)
Minimum amount
12 multiplied by the following amount:
(i)
For 1998, $367 (but not to exceed, in the case of an area outside the 50 States and the District of Columbia, 150 percent of the annual per capita rate of payment for 1997 determined under section
1395mm
(a)(1)(C) of this title for the area).
(ii)
For 1999 and 2000, the minimum amount determined under clause (i) or this clause, respectively, for the preceding year, increased by the national per capita Medicare+Choice growth percentage described in paragraph (6)(A) applicable to 1999 or 2000, respectively.
(C)
Minimum percentage increase
(i)
For 1998, 102 percent of the annual per capita rate of payment for 1997 determined under section
1395mm
(a)(1)(C) of this title for the Medicare+Choice payment area.
(ii)
For 1999 and 2000, 102 percent of the annual Medicare+Choice capitation rate under this paragraph for the area for the previous year.
(iii)
For 2001, 103 percent of the annual Medicare+Choice capitation rate under this paragraph for the area for 2000.
(iv)
For 2002 and 2003, 102 percent of the annual Medicare+Choice capitation rate under this paragraph for the area for the previous year.
(D)
100 percent of fee-for-service costs
(i)
In general
For each year specified in clause (ii), the adjusted average per capita cost for the year involved, determined under section
1395mm
(a)(4) of this title and adjusted as appropriate for the purpose of risk adjustment, for the MA payment area for individuals who are not enrolled in an MA plan under this part for the year, but adjusted to exclude costs attributable to payments under section
1395ww
(h) of this title.
(ii)
Periodic rebasing
The provisions of clause (i) shall apply for 2004 and for subsequent years as the Secretary shall specify (but not less than once every 3 years).
(iii)
Inclusion of costs of VA and DOD military facility services to medicare-eligible beneficiaries
In determining the adjusted average per capita cost under clause (i) for a year, such cost shall be adjusted to include the Secretary’s estimate, on a per capita basis, of the amount of additional payments that would have been made in the area involved under this subchapter if individuals entitled to benefits under this subchapter had not received services from facilities of the Department of Defense or the Department of Veterans Affairs.
(2)
Area-specific and national percentages
For purposes of paragraph (1)(A)—
(A)
for 1998, the “area-specific percentage” is 90 percent and the “national percentage” is 10 percent,
(B)
for 1999, the “area-specific percentage” is 82 percent and the “national percentage” is 18 percent,
(C)
for 2000, the “area-specific percentage” is 74 percent and the “national percentage” is 26 percent,
(D)
for 2001, the “area-specific percentage” is 66 percent and the “national percentage” is 34 percent,
(3)
Annual area-specific Medicare+Choice capitation rate
(A)
In general
For purposes of paragraph (1)(A), subject to subparagraphs (B) and (E), the annual area-specific Medicare+Choice capitation rate for a Medicare+Choice payment area—
(B)
Removal of medical education from calculation of adjusted average per capita cost
(i)
In general
In determining the area-specific Medicare+Choice capitation rate under subparagraph (A) for a year (beginning with 1998), the annual per capita rate of payment for 1997 determined under section
1395mm
(a)(1)(C) of this title shall be adjusted to exclude from the rate the applicable percent (specified in clause (ii)) of the payment adjustments described in subparagraph (C).
(C)
Payment adjustment
(i)
In general
Subject to clause (ii), the payment adjustments described in this subparagraph are payment adjustments which the Secretary estimates were payable during 1997—
(ii)
Treatment of payments covered under State hospital reimbursement system
To the extent that the Secretary estimates that an annual per capita rate of payment for 1997 described in clause (i) reflects payments to hospitals reimbursed under section
1395f
(b)(3) of this title, the Secretary shall estimate a payment adjustment that is comparable to the payment adjustment that would have been made under clause (i) if the hospitals had not been reimbursed under such section.
(D)
Treatment of areas with highly variable payment rates
In the case of a Medicare+Choice payment area for which the annual per capita rate of payment determined under section
1395mm
(a)(1)(C) of this title for 1997 varies by more than 20 percent from such rate for 1996, for purposes of this subsection the Secretary may substitute for such rate for 1997 a rate that is more representative of the costs of the enrollees in the area.
(E)
Inclusion of costs of DOD and VA military facility services to Medicare-eligible beneficiaries
In determining the area-specific MA capitation rate under subparagraph (A) for a year (beginning with 2004), the annual per capita rate of payment for 1997 determined under section
1395mm
(a)(1)(C) of this title shall be adjusted to include in the rate the Secretary’s estimate, on a per capita basis, of the amount of additional payments that would have been made in the area involved under this subchapter if individuals entitled to benefits under this subchapter had not received services from facilities of the Department of Defense or the Department of Veterans Affairs.
(4)
Input-price-adjusted annual national Medicare+Choice capitation rate
(A)
In general
For purposes of paragraph (1)(A), the input-price-adjusted annual national Medicare+Choice capitation rate for a Medicare+Choice payment area for a year is equal to the sum, for all the types of medicare services (as classified by the Secretary), of the product (for each such type of service) of—
(i)
the national standardized annual Medicare+Choice capitation rate (determined under subparagraph (B)) for the year,
(iii)
an index that reflects (for that year and that type of services) the relative input price of such services in the area compared to the national average input price of such services.
In applying clause (iii), the Secretary may, subject to subparagraph (C), apply those indices under this subchapter that are used in applying (or updating) national payment rates for specific areas and localities.
(B)
National standardized annual Medicare+Choice capitation rate
In subparagraph (A)(i), the “national standardized annual Medicare+Choice capitation rate” for a year is equal to—
(C)
Special rules for 1998
In applying this paragraph for 1998—
(i)
medicare services shall be divided into 2 types of services: part A services and part B services;
(ii)
the proportions described in subparagraph (A)(ii)—
(iii)
for part A services, 70 percent of payments attributable to such services shall be adjusted by the index used under section
1395ww
(d)(3)(E) of this title to adjust payment rates for relative hospital wage levels for hospitals located in the payment area involved;
(iv)
for part B services—
(v)
the index values shall be computed based only on the beneficiary population who are 65 years of age or older and who are not determined to have end stage renal disease.
The Secretary may continue to apply the rules described in this subparagraph (or similar rules) for 1999.
(5)
Payment adjustment budget neutrality factor
For purposes of paragraph (1)(A), for each year (other than 2004), the Secretary shall determine a budget neutrality adjustment factor so that the aggregate of the payments under this part (other than those attributable to subsections (a)(3)(C)(iv), (a)(4), and (i) of this section) shall equal the aggregate payments that would have been made under this part if payment were based entirely on area-specific capitation rates.
(6)
“National per capita Medicare+Choice growth percentage” defined
(A)
In general
In this part, the “national per capita Medicare+Choice growth percentage” for a year is the percentage determined by the Secretary, by March 1st before the beginning of the year involved, to reflect the Secretary’s estimate of the projected per capita rate of growth in expenditures under this subchapter for an individual entitled to benefits under part A of this subchapter and enrolled under part B of this subchapter, reduced by the number of percentage points specified in subparagraph (B) for the year. Separate determinations may be made for aged enrollees, disabled enrollees, and enrollees with end-stage renal disease.
(C)
Adjustment for over or under projection of national per capita Medicare+Choice growth percentage
Beginning with rates calculated for 1999, before computing rates for a year as described in paragraph (1), the Secretary shall adjust all area-specific and national Medicare+Choice capitation rates (and beginning in 2000, the minimum amount) for the previous year for the differences between the projections of the national per capita Medicare+Choice growth percentage for that year and previous years and the current estimate of such percentage for such years, except that for purposes of paragraph (1)(C)(v)(II), no such adjustment shall be made for a year before 2004.
(7)
Adjustment for national coverage determinations and legislative changes in benefits
If the Secretary makes a determination with respect to coverage under this subchapter or there is a change in benefits required to be provided under this part that the Secretary projects will result in a significant increase in the costs to Medicare+Choice of providing benefits under contracts under this part (for periods after any period described in section
1395w–22
(a)(5) of this title), the Secretary shall adjust appropriately the payments to such organizations under this part. Such projection and adjustment shall be based on an analysis by the Chief Actuary of the Centers for Medicare & Medicaid Services of the actuarial costs associated with the new benefits.
(d)
MA payment area; MA local area; MA region defined
(1)
MA payment area
In this part, except as provided in this subsection, the term “MA payment area” means—
(2)
MA local area
The term “MA local area” means a county or equivalent area specified by the Secretary.
(3)
Rule for ESRD beneficiaries
In the case of individuals who are determined to have end stage renal disease, the Medicare+Choice payment area shall be a State or such other payment area as the Secretary specifies.
(4)
Geographic adjustment
(A)
In general
Upon written request of the chief executive officer of a State for a contract year (beginning after 1998) made by not later than February 1 of the previous year, the Secretary shall make a geographic adjustment to a Medicare+Choice payment area in the State otherwise determined under paragraph (1) for MA local plans—
(iii)
to consolidating into a single Medicare+Choice payment area noncontiguous counties (or equivalent areas described in paragraph (1)(A)) within a State.
Such adjustment shall be effective for payments for months beginning with January of the year following the year in which the request is received.
(B)
Budget neutrality adjustment
In the case of a State requesting an adjustment under this paragraph, the Secretary shall initially (and annually thereafter) adjust the payment rates otherwise established under this section with respect to MA local plans for Medicare+Choice payment areas in the State in a manner so that the aggregate of the payments under this section for such plans in the State shall not exceed the aggregate payments that would have been made under this section for such plans for Medicare+Choice payment areas in the State in the absence of the adjustment under this paragraph.
(C)
Metropolitan based system
The metropolitan based system described in this subparagraph is one in which—
(i)
all the portions of each metropolitan statistical area in the State or in the case of a consolidated metropolitan statistical area, all of the portions of each primary metropolitan statistical area within the consolidated area within the State, are treated as a single Medicare+Choice payment area, and
(e)
Special rules for individuals electing MSA plans
(1)
In general
If the amount of the Medicare+Choice monthly MSA premium (as defined in section
1395w–24
(b)(2)(C) of this title) for an MSA plan for a year is less than 1/12 of the annual Medicare+Choice capitation rate applied under this section for the area and year involved, the Secretary shall deposit an amount equal to 100 percent of such difference in a Medicare+Choice MSA established (and, if applicable, designated) by the individual under paragraph (2).
(2)
Establishment and designation of Medicare+Choice medical savings account as requirement for payment of contribution
In the case of an individual who has elected coverage under an MSA plan, no payment shall be made under paragraph (1) on behalf of an individual for a month unless the individual—
(A)
has established before the beginning of the month (or by such other deadline as the Secretary may specify) a Medicare+Choice MSA (as defined in section 138(b)(2) of the Internal Revenue Code of 1986), and
(B)
if the individual has established more than one such Medicare+Choice MSA, has designated one of such accounts as the individual’s Medicare+Choice MSA for purposes of this part.
Under rules under this section, such an individual may change the designation of such account under subparagraph (B) for purposes of this part.
(3)
Lump-sum deposit of medical savings account contribution
In the case of an individual electing an MSA plan effective beginning with a month in a year, the amount of the contribution to the Medicare+Choice MSA on behalf of the individual for that month and all successive months in the year shall be deposited during that first month. In the case of a termination of such an election as of a month before the end of a year, the Secretary shall provide for a procedure for the recovery of deposits attributable to the remaining months in the year.
(f)
Payments from Trust Funds
The payment to a Medicare+Choice organization under this section for individuals enrolled under this part with the organization and payments to a Medicare+Choice MSA under subsection (e)(1) of this section shall be made from the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund in such proportion as the Secretary determines reflects the relative weight that benefits under part A of this subchapter and under part B of this subchapter represents of the actuarial value of the total benefits under this subchapter. Payments to MA organizations for statutory drug benefits provided under this subchapter are made from the Medicare Prescription Drug Account in the Federal Supplementary Medical Insurance Trust Fund. Monthly payments otherwise payable under this section for October 2000 shall be paid on the first business day of such month. Monthly payments otherwise payable under this section for October 2001 shall be paid on the last business day of September 2001. Monthly payments otherwise payable under this section for October 2006 shall be paid on the first business day of October 2006.
(g)
Special rule for certain inpatient hospital stays
In the case of an individual who is receiving inpatient hospital services from a subsection (d) hospital (as defined in section
1395ww
(d)(1)(B) of this title), a rehabilitation hospital described in section
1395ww
(d)(1)(B)(ii) of this title or a distinct part rehabilitation unit described in the matter following clause (v) of section
1395ww
(d)(1)(B) of this title, or a long-term care hospital (described in section
1395ww
(d)(1)(B)(iv) of this title) as of the effective date of the individual’s—
(1)
election under this part of a Medicare+Choice plan offered by a Medicare+Choice organization—
(A)
payment for such services until the date of the individual’s discharge shall be made under this subchapter through the Medicare+Choice plan or the original medicare fee-for-service program option described in section
1395w–21
(a)(1)(A) of this title (as the case may be) elected before the election with such organization,
(2)
termination of election with respect to a Medicare+Choice organization under this part—
(A)
the organization shall be financially responsible for payment for such services after such date and until the date of the individual’s discharge,
(B)
payment for such services during the stay shall not be made under section
1395ww
(d) of this title or other payment provision under this subchapter for inpatient services for the type of facility, hospital, or unit involved, described in the matter preceding paragraph (1), as the case may be, or by any succeeding Medicare+Choice organization, and
(h)
Special rule for hospice care
(1)
Information
A contract under this part shall require the Medicare+Choice organization to inform each individual enrolled under this part with a Medicare+Choice plan offered by the organization about the availability of hospice care if—
(2)
Payment
If an individual who is enrolled with a Medicare+Choice organization under this part makes an election under section
1395d
(d)(1) of this title to receive hospice care from a particular hospice program—
(A)
payment for the hospice care furnished to the individual shall be made to the hospice program elected by the individual by the Secretary;
(B)
payment for other services for which the individual is eligible notwithstanding the individual’s election of hospice care under section
1395d
(d)(1) of this title, including services not related to the individual’s terminal illness, shall be made by the Secretary to the Medicare+Choice organization or the provider or supplier of the service instead of payments calculated under subsection (a) of this section; and
(i)
New entry bonus
(1)
In general
Subject to paragraphs (2) and (3), in the case of Medicare+Choice payment area in which a Medicare+Choice plan has not been offered since 1997 (or in which all organizations that offered a plan since such date have filed notice with the Secretary, as of October 13, 1999, that they will not be offering such a plan as of January 1, 2000, or filed notice with the Secretary as of October 3, 2000, that they will not be offering such a plan as of January 1, 2001), the amount of the monthly payment otherwise made under this section shall be increased—
(2)
Period of application
Paragraph (1) shall only apply to payment for Medicare+Choice plans which are first offered in a Medicare+Choice payment area during the 2-year period beginning on January 1, 2000.
(3)
Limitation to organization offering first plan in an area
Paragraph (1) shall only apply to payment to the first Medicare+Choice organization that offers a Medicare+Choice plan in each Medicare+Choice payment area, except that if more than one such organization first offers such a plan in an area on the same date, paragraph (1) shall apply to payment for such organizations.
(4)
Construction
Nothing in paragraph (1) shall be construed as affecting the calculation of the annual Medicare+Choice capitation rate under subsection (c) of this section for any payment area or as applying to payment for any period not described in such paragraph and paragraph (2).
(5)
Offered defined
In this subsection, the term “offered” means, with respect to a Medicare+Choice plan as of a date, that a Medicare+Choice eligible individual may enroll with the plan on that date, regardless of when the enrollment takes effect or when the individual obtains benefits under the plan.
(j)
Computation of benchmark amounts
For purposes of this part, the term “MA area-specific non-drug monthly benchmark amount” means for a month in a year—
(1)
with respect to—
(A)
a service area that is entirely within an MA local area, subject to section
1395w–29
(d)(2)(A) of this title, an amount equal to 1/12 of the annual MA capitation rate under subsection (c)(1) of this section for the area for the year, adjusted as appropriate for the purpose of risk adjustment; or
(B)
a service area that includes more than one MA local area, an amount equal to the average of the amounts described in subparagraph (A) for each such local MA area, weighted by the projected number of enrollees in the plan residing in the respective local MA areas (as used by the plan for purposes of the bid and disclosed to the Secretary under section
1395w–24
(a)(6)(A)(iii) of this title), adjusted as appropriate for the purpose of risk adjustment; or
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