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Medicare Advantage Quality Improvement Programs

MMA Statutory Language: Section 722

Section 722 amends Social Security Act Section 1852(e), now titled Quality Improvement Program.

SEC. 722. MEDICARE ADVANTAGE QUALITY IMPROVEMENT PROGRAMS

(a) IN GENERAL. — Section 1852(e) (42 U.S.C. 1395w–22(e)) is amended —

(1) in the heading, by striking “ASSURANCE” and inserting “IMPROVEMENT”;
(2) by amending paragraphs (1) through (3) to read as follows:
(1) IN GENERAL. — Each MA organization shall have an ongoing quality improvement program for the purpose of improving the quality of care provided to enrollees in each MA plan offered by such organization (other than an MA private fee- for-service plan or an MSA plan).
(2) CHRONIC CARE IMPROVEMENT PROGRAMS. — As part of the quality improvement program under paragraph (1), each MA organization shall have a chronic care improvement program. Each chronic care im provement program shall have a method for monitoring and identifying enrollees with multiple or sufficiently severe chronic conditions that meet criteria established by the organization for participation under the program.
(3) DATA. —

(A) COLLECTION, ANALYSIS, AND REPORTING. —

(i) IN GENERAL. — Except as provided in clauses (ii) and (iii) with respect to plans described in such clauses and subject to subparagraph (B), as part of the quality improve- ment program under paragraph (1), each MA organization shall provide for the collection, analysis, and reporting of data that permits the measurement of health outcomes and other indices of quality.
(ii) APPLICATION TO MA REGIONAL PLANS. — The Secretary shall establish as appropriate by regulation require- ments for the collection, analysis, and reporting of data that permits the measurement of health outcomes and other indices of quality for MA organizations with respect to MA regional plans. Such requirements may not exceed the requirements under this subparagraph with respect to MA local plans that are preferred provider organization plans.
(iii) APPLICATION TO PREFERRED PROVIDER ORGANIZATIONS. — Clause (i) shall apply to MA organizations with respect to MA local plans that are pre- ferred provider organization plans only insofar as services are furnished by providers or services, physicians, and other health care practitioners and suppliers that have contracts with such organization to furnish services under such plans.
(iv) DEFINITION OF PREFERRED PROVIDER ORGANIZATION PLAN. — In this subparagraph, the term ‘preferred provider organization plan’ means an MA plan that

(I) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan;
(II) provides for reimbursement for all covered benefits regardless of whether such benefits are provided within such network of providers; and
(III) is offered by an organization that is not licensed or organized under State law as a health maintenance organization.

(B) LIMITATIONS. —

(i) TYPES OF DATA. — The Secretary shall not collect under subparagraph (A) data on quality, outcomes, and beneficiary satisfaction to facilitate consumer choice and program administration other than the types of data that were collected by the Secretary as of November 1, 2003.
(ii) CHANGES IN TYPES OF DATA. — Subject to sub- clause
(iii), the Secretary may only change the types of data that are required to be submitted under subparagraph (A) after submitting to Congress a report on the reasons for such changes that was prepared in consultation with MA organi- zations and private accrediting bodies.
(iii) CONSTRUCTION. — Nothing in the subsection shall be construed as restricting the ability of the Secretary to carry out the duties under section 1851(d)(4)(D).;

(3) in paragraph (4)(B) —

(A) by amending clause (i) to read as follows:

(i) Paragraphs (1) through (3) of this subsection (relating to quality improvement programs); and

(B) by adding at the end the following new clause:
(vii) The requirements described in section 1860D–4(j), to the extent such requirements apply under section 1860D– 21(c); and

(4) by striking paragraph (5).

(b) CONFORMING AMENDMENT. — Section 1852(c)(1)(I) (42 U.S.C. 1395w–22(c)(1)(I)) is amended to read as follows:

(I) QUALITY IMPROVEMENT PROGRAM. — A description of the organization’s quality improvement program under subsection (e).

(c) EFFECTIVE DATE. — The amendments made by this section shall apply with respect to contract years beginning on and after January 1, 2006.