C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 417—HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS › Subpart P—Medicare Payment: Risk Basis

42 C.F.R. § 417.584

Payment to HMOs or CMPs with risk contracts

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Except in the circumstances specified in § 417.440(d) for inpatient hospital care, and as provided in § 417.585 for hospice care, CMS makes payment for covered services only to the HMO or CMP.

(a) Principle of payment. CMS makes monthly advance payments equivalent to the HMO's or CMP's per capita rate of payment for each beneficiary who is registered in CMS records as a Medicare enrollee of the HMO or CMP.

(b) Determination of rate. (1) The annual per capita rate of payment for each class of Medicare enrollees is equal to 95 percent of the AAPCC (as determined under the provisions of § 417.588) for that class of Medicare enrollees.

(2) CMS furnishes each HMO or CMP with its per capita rate of payment for each class of Medicare enrollees not later than 90 days before the beginning of the HMO's or CMP's contract period.

(c) Adjustments to payments. If the actual number of Medicare enrollees differs from the estimated number on which the amount of advance monthly payment was based, CMS adjusts subsequent monthly payments to take account of the difference.

(d) Reduction of payments. If an HMO or CMP requests a reduction in its monthly payment in accordance with § 417.592(b)(2), CMS reduces the amount of payment by the appropriate amount.

(e) Determination of rate for calendar year 1998. For calendar year 1998, HMOs or CMPs with risk contracts will be paid in accordance with principles contained in subpart F of part 422 of this chapter.

[50 FR 1346, Jan. 10, 1985; 50 FR 20570, May 17, 1985, as amended at 52 FR 8901, Mar. 20, 1987; 58 FR 38082, July 15, 1993; 60 FR 46232, Sept. 6, 1995; 63 FR 35067, June 26, 1998]
Notes of Decisions
Cited in 2 cases, 1998–2000 · leading case: Minnesota Ex Rel. Hatch v. United States, 102 F. Supp. 2d 1115 (D. Minnesota 2000).
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Minnesota Ex Rel. Hatch v. United States, 102 F. Supp. 2d 1115 (D. Minnesota 2000). · cites it 2× “§ 1395mm(a)(4); see 42 C.F.R. § 417.584 . The AAPCC was Medicare’s estimate of the average per capita amount it would cost to treat a given beneficiary under the fee-for-service system.”
Zamora-Quezada v. HealthTexas Med. Grp., 34 F. Supp. 2d 433 (W.D. Tex. 1998). “§ 1395mm(a); 42 C.F.R. § 417.584 (1997) (HCFA payment allowances for covered services to HMOs with risk contracts); 42 C.”
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