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Medicare program; establishment of the Medicare Advantage Program; interpretation. Final rule; interpretation

    Federal Register
    |March 25, 2005
    PubMed

    Insights

    This final rule clarifies the definition of "entity" for Medicare Advantage (MA) organizations. It confirms that a joint enterprise of health plans can contract as a single entity to offer an MA Regional Plan.

    Area of Science:

    • Health Policy and Regulation
    • Medicare Program Administration
    • Health Insurance Law

    Background:

    • The Medicare Advantage (MA) final rule was published on January 28, 2005.
    • Inquiries were received regarding the formation of joint enterprises for MA Regional Plans.
    • Health plans sought to contract as a single entity in multistate regions.

    Purpose of the Study:

    • To clarify the interpretation of the term "entity" within the MA program.
    • To determine if a joint enterprise qualifies as a single "entity" for contracting purposes.
    • To address inquiries concerning the offering of MA Regional Plans by joint ventures.

    Main Methods:

    • Interpretation of existing regulations and legal definitions.
    • Analysis of sections 1859(a)(1) and 1855(a)(1) of the Social Security Act.
    • Issuance of a final rule clarifying regulatory language.

    Main Results:

    • A joint enterprise of health plans can be considered a single "entity" under the Social Security Act.
    • This clarification applies to offering Medicare Advantage Regional Plans.
    • The interpretation is integrated into the January 28, 2005, MA final rule.

    Conclusions:

    • Health plans can collaborate to form a joint enterprise to offer MA Regional Plans.
    • The definition of "entity" accommodates joint ventures for MA program participation.
    • This clarification facilitates the expansion of MA Regional Plan offerings.

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