Page:United States Statutes at Large Volume 102 Part 1.djvu/739

 'i«i*i^r '".^'^--'^^

PUBLIC LAW 100-360—JULY 1, 1988

102 STAT. 701

such an organization if payments were made other than under such clause or such a contract on an individual-by-individual basis. "(5)(A) Except as provided in subparagraph (B), expenses incurred by a medicare beneficiary for out-of-pocket part B cost-sharing shall be counted (consistent with subparagraph (C)) whether or not, at the time the expenses were incurred, the beneficiary was enrolled in a plan under section 1833(a)(l)(A) or under section 1876. In this paragraph, with respect to a medicare beneficiary enrolled in such a plan, the term 'out-of-pocket part B cost-sharing* includes deductibles and coinsurance under the plan for items and services covered under this part. "(B) In the case of a medicare beneficiary enrolled in a month in a buy-out plan (as defined in subparagraph (D))— "(i) expenses incurred by the beneficiary for items and services reimbursed under the plan shall not be treated as out-ofpocket part B cost-sharing for purposes of paragraph (1), but "(ii) the beneficiary is deemed to have incurred, for each month of such enrollment, expenses for out-of-pocket part B cost-sharing in an amount equal to the actuarial value (with respect to a month in the year involved) of the deductible and coinsurance amounts under part B (as computed by the Secretary for purposes of section 1876(e)(l), other than with respect to covered outpatient drugs) applicable on the average to individuals in the United States. "(C) The Secretary may not enter into a contract with an Contracts. organization under section 1876, or provide for payment under section 1833(a)(l)(A) with respect to an organization, with respect to a plan that is not a buy-out plan, unless the organization provides assurances, satisfactory to the Secretary, that— "(i) the organization will maintain and make available, for its enrollees and in coordination with the appropriate carriers under this part, an accounting of expenses incurred in each year under the plan for out-of-pocket part B cost-sharing (as defined in subparagraph (A)); and "(ii) the organization will not undertake to charge a beneficiary during a year for services for which payment may be made under this part (other than for covered outpatient drugs) after the individual has incurred (whether through the organization or otherwise) out-of-pocket part B cost sharing in the year in an amount equal to the part B catastrophic limit established under paragraph (1) for the year. "(D) In this paragraph, the term 'buy-out plan' means a plan under section 1833(a)(l)(A) or offered by an organization under section 1876 and with respect to which— "(i) the actuarial vahie of the coinsurance and deductibles under the plan with respect to benefits (other than covered outpatient drugs) under this title (as determined by the Secretary), is less than 50 percent of— "(ii) the actuarial value of the coinsurance and deductibles for such benefits for all medicare beneficiaries (as determined by the Secretary) applicable on the average to individuals in the United States. "(E) In this subsection, the term 'medicare beneficiary' means, with respect to a month, an individual covered for benefits under this part for the month.".

�