Former Welfare Families Independence and Recurring Dependency

care, an organlzntlon must have st least half of Its enrolled membership composed of persons under age 65 and must have an open-enrollment perxod durmg uh~ch It R 111 accept Medlcnre beneficnmes to the lnmts of Its cnpaclty m the order ,n \\hlch they apply (\%lth prowaons for RBIYB~‘S and exceptlox) The HMO premmm rate or otha charge to MedIcare enrollees need not be commumty-rated but can be bnsed on the actunrml value of the BIedxare deductible plus any co1nsumnce The new lan contmues the requnwnent that the serv~es nn HMO must provide t,o Medicare beneficlarles are those covered under that, program’s hosplt,sl msurnnce and supplementary medlcnl msurance mther thRn the “bsslc health servmes” defined m the HMO Act The requwement m the Social Security Act that an HMO must provide both prunary care and speaalty care physwns for Its members has been elumnated R-ow, m determmmg the amounts paya,ble to It under R risk-sharmg contract mlth the Secret,ary of Health, Education, and Welfare, an HMO may Include remsurance costs stemmmg from a,ny underwrltmg of cntastrophx nsks Previously, only re1nsuranee costs relating to out-of-area serv,ces were allox%ed Medmsld prov~s,ons have been amended to melude a defimtlon of HMO’s that corresponds to the defimtlon m the HMO Act m all respects except that “baw health servxes” are defined as referrmg to mandatory Rfedlcsld services Unless the provwon 1s wawed, no more than half the enrolless m an HMO may be covered under Medtcare or be reclplents of Medlcald The nev law tlghtens up the prov~slons for Federal mstchmg payments to States for Medlcad SWVKRS provided by orgnmzatlons on a prepaId or capltatlon at-nsk bnsls No payments ~11 be made unless the organlzatlon provldmg mp&lent hospital services, any other mnndnt,ed Medxsld service, or any three other Medvxud servxes on a prepad risk baa has qunhfied RS an HMO Exempted from this requwnent are orgnmzntlons that have recawd commumty health center or migrant he&h service grants of specified amounts and nonprofit rural health care enthes that have recaved specified grants under the Appalachmn Reg~onnl Development Act The requirement n1ll not xpply to orgnnlzatlons t11at contracted for the prowsmn of S~L’YICRS before