Page:United States Statutes at Large Volume 101 Part 2.djvu/919

 PUBLIC LAW 100-203—DEC. 22, 1987

101 STAT. 1330-125

deems to be fair and equitable taking into consideration benefits attributable to such parts A and B, respectively. (6) During any period in which an individual is enrolled with an eligible organization conducting a demonstration project under this section, only the eligible organization (and no other individual or person) shall be entitled to receive payments from the Secretary under this title for community nursing and ambulatory care (as defined in subsection (b)(1)) furnished to the individual. (e) RESTRICTION ON PREMIUMS, DEDUCTIBLES, COPAYMENTS, AND COINSURANCE.—

(1) In no case may the portion of an eligible organization's premium rate and the actuarial value of its deductibles, coinsurance, and copayments charged (with respect to community nursing and ambulatory care) to individuals who are enrolled under this section with the organization, exceed the actuarial value of the coinsurance and deductibles that would be applicable on the average to individuals enrolled under this section with the organization (or, if the Secretary finds that adequate data are not available to determine that actuarial value, the actuarial value of the coinsurance and deductibles applicable on the average to individuals in the area, in the State, or in the United States, eligible to enroll under this section with the organization, or other appropriate data) and entitled to benefits under part A and enrolled under part B of the Social Security Act, if they were not members of an eligible organization. (2) If the eligible organization provides to its members enrolled under this section services in addition to community nursing and ambulatory care, election of coverage for such additional services shall be optional for such members and such organization shall furnish such members with information on the portion of its premium rate or other charges applicable to such additional services. In no case may the sum of^ (A) the pwrtion of such organization's premium rate charged, with respect to such additional services, to mem#iJis» bers enrolled under this section, and (B) the actuarial value of its deductibles, coinsurance, and '^^ Scopayments charged, with respect to such services to such members exceed the adjusted community rate for such services (as defined in section 1876(e)(3) of the Social Security Act). (3)(A) Subject to subparagraphs (B) and (C), each agreement to conduct a demonstration project under this section shall provide that if— (i) the adjusted community rate, referred to in paragraph (2), for community nursing and ambulatory care covered - '^ under parts A and B of title XVIII of the Social Security Act (as reduced for the actuarial value of the coinsurance and deductibles under those parts) for members enrolled under this section with the organization, is less than (ii) the average of the per capita rates of payment to be made under subsection (d)(1) at the beginning of the 12month period (as determined on such basis as the Secretary determines appropriate) described in such subsection for members enrolled under this section with the organization.

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