54 and representatives of associations of retired persons or associations otherwise representative of Medicare bene- established only after public hearing.127 This system would apply only to services in the United States and not year. 130 The Secretary of HEW would be required to make public for each local area the established fee schedule for the area, and the names, professional fields and professional addresses of the participating practitioners in the area. In other cases, a participating non-institutional provider (pharmacy, etc.) is to be paid on a "reasonable charge" basis, 131 except that a non-profit organization that runs on a prepayment basis may on its request be reimbursed under the provisions for payments to institutional providers.132 In emergencies, if the service the United States is furnished by a non-participating 126Medicare Amendments of 1974, §§111 (a) ("1836 (d) (2) (C)"). ("1836 (b) (1) (B)"). ("1836 (b) (2) (B)"). in - 55 6. agreement with the Secretary), payment of the "reasonable charge" may be made either to the patient on the basis of an itemized bill, or to the provider on assignment from the patient if the provider agrees that the reasonable charge is his full charge.133 The Medicare Amendments of 1974 merged the present Hospital Insurance provisions for use of fiscal intermediaries and the Supplementary Medical Insurance provisions for the use of carriers into a single section providing for use of carriers (including the type of organization which under the present system is a fiscal intermediary under Hospital Insurance in the administration of the program), but adding the above-noted new functions relating to budgets and predetermined, approved rates for institutional providers and the negotiation and establishment of fee schedules for non-institutional The Secretary must give priority to the fiscal intermediary types of organizations in selecting "carriers" to act for him with respect to covered services provided by institutional providers for which payment is 135 to be made on an approved charge basis. Payments to Health Maintenance Organizations services. 134 a. Present Law Under present law, as amended by the Social Security Amendments of 1972, the reimbursement to health maintenance 133 Medicare Amendments of 1974, 134Medicare Amendments of 1974, 135Medicare Amendments of 1974, §§111 (a) ("1836 (a) (2)"). 34-275 (Pt. 8) O 75 12 7. organizations is made either on a risk-sharing or cost b. The Medicare Amendments of 1974 Under the Medicare Amendments of 1974, the provisions Other Changes to Coordinate the Availability and Delivery a. Present Law With the enactment of the Health Insurance for the 136Soc. Sec. Act §§1876. Secretary of HEW finds that an organization proposing and eligible to qualify as a participating HMO cannot be incorporated or otherwise do business in a state in which it proposes to provide covered services because of state laws which the Secretary finds restrictive or otherwise incompatible with the Health Insurance program, he may issue a certificate of incorporation to the organization and the restrictive state laws will not apply. 13 Medicare Amendments of 1974, 13 Medicare Amendments of 1974, §§111 (d) (6) ("1838 (b) (3) (C)"). aged and that it would pay its beneficiaries, or on their behalf without regard to any other benefits that might be payable under an employee health benefits plan. Such plans were expected to adjust their benefit policies to supplement and compliment the protection provided under Medicare, rather than duplicate benefits. Under present law, federal employees and annuitants who enroll for federal employee health benefits may also be covered under the Health Insurance for the Aged and Disabled programs. The Federal Government has not adjusted the health insurance protection it makes available to its employees and annuitants to make such protection supplementary to Hospital and Supplementary Medical Insurance. The FEHB plans consequently duplicate many benefits. In cases where health care expenses are covered under Hospital and/ or Supplementary Medical Insurance and an FEHB plan, the Hospital and/or Supplementary Medical Insurance benefits are paid first and the FEHB plan then pays in an amount which, when added to the benefit amounts already payable, may not exceed 100 per cent of the expenses allowable under the FEHB plan. The law was amended, effective after 1974, to assure that no payment will be made under Hospital Insurance or Supplementary Medical Insurance, for any item or service that is also covered and furnished under an FEHB program. This provision will not apply if, prior to date, an item or service is furnished, the Secretary of HEW determines and certifies that the FEHB program has been modified to assure that there is available to federal employees or annuitants one or more FEHB plans that supplement the combined protection of both the Hospital and Supplementary Medical Insurance programs, the Hospital Insurance program alone, and the Supplementary Medical Insurance program alone. Moreover, the FEHB program must be found to be making a contribution towards the health insurance of each federal employee or annuitant that equals its contribution for high option coverage under the government-wide FEHB plans. The contribution, whether by the federal government or by the individual plan, may be in the form of a contribution towards the supplementary FEHB program or a payment to or on behalf of the individual employee or annuitant to offset the cost of his purchase of Medicare protection, or a combination of the two. The Medicare Amendments of 1974 would replace the 1972 provisions to take into account the structural changes in the law and the elimination of premiums under the Health Insurance program and clarify the intent of the 1972 Amendments. Specifically, each FEHB plan would be required to offer to eligible enrollees, under a distinct 140Soc. Sec. Act §§1862 (c). 140 |