1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 65 (2) provides for 12-month coverage terms; (3) does not permit any exclusion from, or limita tion with regard to, coverage of an individual because of health status (pre-existing, current, or future), economic status, race, sex, occupation, age or establishment of any other condition inconsistent with regulations of the Secretary but this paragraph shall not be construed to preclude reasonable classification of risks for premium rate purposes in accordance with actuarial principles; and (4) contains such provisions as the Secretary may prescribe or approve relating to coordination of the coverage under the insurance contract or prepayment plan involved with overlapping or duplicative coverages under other insurance contracts or prepayment plans. CONTRACTS WITH HEALTH CARE CORPORATIONS ON CAPITATION BASIS SEC. 135. In the case of a Health Care Corporation that 18 operates on the basis of predetermined capitation charges 19 (approved by the appropriate State Health Commission), 20 the Secretary may, if satisfied as to the corporation's financial 21 responsibility to qualify as a carrier for itself under this sec22 tion, provide the coverage for Comprehensive Health Care 23 Benefits under this Act to which registrants of the corpora24 tion are entitled under section 102 (b), by entering (directly or through the State Health Commission as the Secretary's 25 H.R. 1-5 66 1 agent as authorized by section 217 (b) (2)) into a contract 2 with the corporation, whereby the Secretary, in consideration 3 of the corporation's undertaking to provide (or, when au4 thorized under part D of title II, pay for) the services and 5 items covered by such benefits, agrees that there shall be 6 paid by the Secretary to the corporation, with respect to 7 those registrants of the corporation who enroll under the 8 contract, the same amounts that a third-party carrier would 9 be required to pay under a contract with the Secretary, 10 except that a contract under this section (1) shall authorize the Secretary in the case of a Health Care Corporation that does not impose separate charges equivalent to copayments in addition to capitation charges, to deduct, from any capitation payments otherwise payable by the Secretary to the corporation on behalf of an individual enrolled under the contract, the value (as determined on the basis of actuarial principles) of any copayments to which the covered registrants would be subject under part B of this title if the corporation imposed separate charges equivalent to copayments; (2) shall not, in the case of a Health Care Corporation that imposes separate charges equivalent to copay ments in addition to capitation charges, undertake to pay those charges to the corporation; 1 2 3 4 5 6 7 བ 8 9 10 67 (3) shall provide that the corporation shall itself collect from a registrant (or from others on his behalf) all copayments and premium contributions (in the form of capitation charges) payable by the registrant, and shall keep for the registrant the record of such copay. ments and contributions incurred by him (or his faınily) and notify him when he has reached the applicable ex penditure limit under section 125 giving rise to Catastrophic Expense Benefits; and (4) shall require the corporation to establish, in 11 accordance with regulations or with provisons in the 12 13 14 2 3 4 9 15 16 17 18 contract, effective procedures (through such means as establishment of a separate record and payment center and issuance of identical membership cards to all its registrants, regardless of whether they have benefit coverage purchased by the Secretary) that will prevent persons who furnish health services or items for the corporation from identifying those registrants who enjoy coverage purchased by the Secretary and discriminating against them on that account. 21 Any reference in this part to premiums, or contributions to 22 premiums, shall be deemed to include capitation amounts 23 paid by the Secretary, or contributions to capitation charges 24 by registrants, respectively, under contracts made under this 25 section. 68 EFFECT OF NONPAYMENT OF PREMIUMS 1 2 SEC. 136. (a) Premium contributions and special pre 3 miums payable pursuant to section 106, by individuals re4 ferred to therein who are enrolled under a contract under this 5 title, shall be paid by or on behalf of the registrant to the 6 carrier (from sources other than the Secretary) in periodic 7 installments in advance in a manner and at the time or times 8 perscribed in regulations of the Secretary but not less often 9 than quarterly nor more often than monthly. 10 (b) In the event of nonpayment of a contribution or 11 special premium installment, when due, to the carrier by or 12 on behalf of an individual, the benefit coverage to which 13 the overdue installment relates shall, upon notice by the 14 carrier in accordance with regulations of the Secretary, 15 end unless payment is made prior to the expiration of a 16 grace period (not in excess of 90 days) prescribed by the 17 regulations, except that (1) the manner and order of termi18 nation of coverage of family members in the event of partial 19 delinquency or default in family contribution installments 20 payable under section 106 shall be determined in accordance 21 with regulations, (2) delinquency or default in contribution 22 installments under section 106 shall not affect the coverage of 23 any family member who has attained the age of 65, and 24 (3) delay in payment shall not give rise to termination 25 of coverage if attributable to an act or omission of a Federal 69 1 officer or employee used as a conduit for transmitting such 2 installments. 3 4 ENROLLMENT UNDER CONTRACTS WITH CARRIERS SEC. 137. (a) The Secretary may by regulations con 5 sistent with other provisions of this Act, prescribe the time 6 or times at which, the manner in which, and the conditions. 7 under which individuals may (1) enroll, under a contract 8 made under this part, for Comprehensive Health Care 9 Benefits coverage purchased by the Secretary to which 10 under section 102 they are entitled, or (2) change enrollment under one contract to enrollment under another. 11 12 (b) The regulations under this section shall permit 13 enrollment by an individual for himself only, or for himself 14 and his spouse and other individuals who are members of 15 his family (as defined in section 105(b)), and shall pre16 scribe the times at which, the manner in which, and the 17 conditions under which a change from one such type of 18 enrollment to another may be made. An individual enrolling 19 for himself and family shall be liable for any premium con20 tributions on which entitlement to family coverage is 21 conditioned. 22 (c) To the optimum extent, (1) open enrollment peri23 ods under this section and open periods for registration with 24 Health Care Corporations approved by State commissions 25 under approved State plans under this Act shall be closely |