42 U.S.C. § 1395ll — Studies and recommendations

Page 3706 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395ll 1 So in original. Probably should be followed by a comma. Section was enacted as part of the Medicare Access and CHIP Reauthorization Act of 2015, and not as part of the Social Security Act which comprises this chap- ter. § 1395ll. Studies and recommendations (a) Health care of the aged and disabled The Secretary shall carry on studies and de- velop recommendations to be submitted from time to time to the Congress relating to health care of the aged and the disabled, including studies and recommendations concerning (1) the adequacy of existing personnel and facilities for health care for purposes of the programs under parts A and B of this subchapter; (2) methods for encouraging the further development of efficient and economical forms of health care which are a constructive alternative to inpatient hospital care; and (3) the effects of the deductibles and coinsurance provisions upon beneficiaries, per- sons who provide health services, and the fi- nancing of the program. (b) Operation and administration of insurance programs The Secretary shall make a continuing study of the operation and administration of this sub- chapter (including a validation of the accredita- tion process of national accreditation bodies under section 1395bb(a) of this title 1 the oper- ation and administration of health maintenance organizations authorized by section 226 of the Social Security Amendments of 1972 [42 U.S.C. 1395mm], the experiments and demonstration projects authorized by section 402 of the Social Security Amendments of 1967 [42 U.S.C. 1395b–1] and the experiments and demonstration projects authorized by section 222(a) of the Social Secu- rity Amendments of 1972 [42 U.S.C. 1395b–1 note]), and shall transmit to the Congress annu- ally a report concerning the operation of such programs. (Aug. 14, 1935, ch. 531, title XVIII, § 1875, as added Pub. L. 89–97, title I, § 102(a), July 30, 1965, 79 Stat. 332; amended Pub. L. 90–248, title IV, § 402(c), Jan. 2, 1968, 81 Stat. 931; Pub. L. 92–603, title II, §§ 201(c)(7), 222(c), 226(d), 244(d), Oct. 30, 1972, 86 Stat. 1373, 1393, 1404, 1423; Pub. L. 98–369, div. B, title III, § 2354(b)(17), July 18, 1984, 98 Stat. 1101; Pub. L. 99–509, title IX, § 9316(a), Oct. 21, 1986, 100 Stat. 2006; Pub. L. 100–203, title IV, § 4085(i)(20), Dec. 22, 1987, 101 Stat. 1330–133; Pub. L. 100–647, title VIII, § 8413, Nov. 10, 1988, 102 Stat. 3801; Pub. L. 101–234, title III, § 301(b)(5), (d)(2), Dec. 13, 1989, 103 Stat. 1985, 1986; Pub. L. 101–239, title VI, § 6103(b)(3)(A), Dec. 19, 1989, 103 Stat. 2199; Pub. L. 108–173, title I, § 101(e)(7), Dec. 8, 2003, 117 Stat. 2152; Pub. L. 110–275, title I, § 125(b)(4), July 15, 2008, 122 Stat. 2519.) Editorial Notes REFERENCES IN TEXT Section 226 of the Social Security Amendments of 1972, referred to in subsec. (b), is section 226 of Pub. L. 92–603, which enacted section 1395mm of this title and provisions set out as notes under that section and amended this section and sections 1395f, 1395l, and 1396b of this title. Section 402 of the Social Security Amendments of 1967, referred to in subsec. (b), is section 402 of Pub. L. 90–248, which enacted section 1395b–1 of this title and amended this section. Section 222(a) of the Social Security Amendments of 1972, referred to in subsec. (b), is section 222(a) of Pub. L. 92–603, which enacted provisions set out as note under section 1395b–1 of this title. AMENDMENTS 2008—Subsec. (b). Pub. L. 110–275 substituted ‘‘na- tional accreditation bodies under section 1395bb(a) of this title’’ for ‘‘the Joint Commission on Accreditation of Hospitals,’’. 2003—Subsec. (b). Pub. L. 108–173 substituted ‘‘this subchapter’’ for ‘‘the insurance programs under parts A and B of this subchapter’’. 1989—Subsec. (c). Pub. L. 101–239 struck out subsec. (c) which related to patient outcome assessment re- search program. Subsec. (c)(7). Pub. L. 101–234, § 301(b)(5), (d)(2), amended par. (7) identically, substituting ‘‘date of the enactment of this section’’ for ‘‘date of the enactment of this Act’’. 1988—Subsec. (c)(3). Pub. L. 100–647 amended par. (3) generally. Prior to amendment, par. (3) read as follows: ‘‘For purposes of carrying out the research program, there are authorized to be appropriated— ‘‘(A) from the Federal Hospital Insurance Trust Fund $4,000,000 for fiscal year 1987 and $5,000,000 for each of fiscal years 1988 and 1989, and ‘‘(B) from the Federal Supplementary Medical In- surance Trust Fund $2,000,000 for fiscal year 1987 and $2,500,000 for each of fiscal years 1988 and 1989.’’ 1987—Subsec. (c)(3)(B). Pub. L. 100–203 substituted ‘‘fiscal year 1987’’ for ‘‘fiscal years 1987’’. 1986—Subsec. (c). Pub. L. 99–509 added subsec. (c). 1984—Subsec. (b). Pub. L. 98–369 struck out ‘‘the’’ after ‘‘Joint Commission on’’. 1972—Subsec. (a). Pub. L. 92–603, § 201(c)(7), inserted ‘‘and the disabled’’ after ‘‘aged’’. Subsec. (b). Pub. L. 92–603, §§ 222(c), 226(d)(1), 244(d), substituted ‘‘(including a validation of the accredita- tion process of the Joint Commission on the Accredita- tion of Hospitals, the operation and administration of health maintenance organizations authorized by sec- tion 226 of the Social Security Amendments of 1972, the experiments and demonstration projects authorized by section 402 of the Social Security Amendments of 1967 and the experiments and demonstration projects au- thorized by section 222(a) of the Social Security Amendments of 1972)’’ for ‘‘(including the experimen- tation authorized by section 402 of the Social Security Amendments of 1967)’’. Pub. L. 92–603, § 226(d)(2), which directed the substitution of ‘‘1972’’ for ‘‘1971’’, could not be executed because ‘‘1971’’ did not appear. 1968—Subsec. (b). Pub. L. 90–248 inserted ‘‘(including the experimentation authorized by section 402 of the Social Security Amendments of 1967’’ after ‘‘under parts A and B of this subchapter’’. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 2008 AMENDMENT; TRANSITION RULE Amendment by Pub. L. 110–275 applicable with re- spect to accreditations of hospitals granted on or after the date that is 24 months after July 15, 2008, with tran- sition rule, see section 125(d) of Pub. L. 110–275, set out as a note under section 1395bb of this title. EFFECTIVE DATE OF 1989 AMENDMENT Pub. L. 101–239, title VI, § 6103(b)(3)(A), Dec. 19, 1989, 103 Stat. 2199, provided that the amendment made by that section is effective for fiscal years beginning after fiscal year 1990. EFFECTIVE DATE OF 1984 AMENDMENT Amendment by Pub. L. 98–369 effective July 18, 1984, but not to be construed as changing or affecting any Page 3707 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395ll right, liability, status, or interpretation which existed (under the provisions of law involved) before that date, see section 2354(e)(1) of Pub. L. 98–369, set out as a note under section 1320a–1 of this title. EFFECTIVE DATE OF 1972 AMENDMENT Amendment by section 226(d) of Pub. L. 92–603 effec- tive with respect to services provided on or after July 1, 1973, see section 226(f) of Pub. L. 92–603, set out as an Effective Date note under section 1395mm of this title. INSTITUTE OF MEDICINE EVALUATION AND REPORT ON HEALTH CARE PERFORMANCE MEASURES Pub. L. 108–173, title II, § 238, Dec. 8, 2003, 117 Stat. 2213, provided that: ‘‘(a) EVALUATION.— ‘‘(1) IN GENERAL.—Not later than the date that is 2 months after the date of the enactment of this Act [Dec. 8, 2003], the Secretary [of Health and Human Services] shall enter into an arrangement under which the Institute of Medicine of the National Acad- emy of Sciences (in this section referred to as the ‘In- stitute’) shall conduct an evaluation of leading health care performance measures in the public and private sectors and options to implement policies that align performance with payment under the medicare program under title XVIII of the Social Se- curity Act (42 U.S.C. 1395 et seq.). ‘‘(2) SPECIFIC MATTERS EVALUATED.—In conducting the evaluation under paragraph (1), the Institute shall— ‘‘(A) catalogue, review, and evaluate the validity of leading health care performance measures; ‘‘(B) catalogue and evaluate the success and util- ity of alternative performance incentive programs in public or private sector settings; and ‘‘(C) identify and prioritize options to implement policies that align performance with payment under the medicare program that indicate— ‘‘(i) the performance measurement set to be used and how that measurement set will be up- dated; ‘‘(ii) the payment policy that will reward per- formance; and ‘‘(iii) the key implementation issues (such as data and information technology requirements) that must be addressed. ‘‘(3) SCOPE OF HEALTH CARE PERFORMANCE MEAS- URES.—The health care performance measures de- scribed in paragraph (2)(A) shall encompass a variety of perspectives, including physicians, hospitals, other health care providers, health plans, purchasers, and patients. ‘‘(4) CONSULTATION WITH MEDPAC.—In evaluating the matters described in paragraph (2)(C), the Institute shall consult with the Medicare Payment Advisory Commission established under section 1805 of the So- cial Security Act (42 U.S.C. 1395b–6). ‘‘(b) REPORT.—Not later than the date that is 18 months after the date of enactment of this Act [Dec. 8, 2003], the Institute shall submit to the Secretary and appropriate committees of jurisdiction of the Senate and House of Representatives a report on the evalua- tion conducted under subsection (a)(1) describing the findings of such evaluation and recommendations for an overall strategy and approach for aligning payment with performance, including options for updating per- formance measures, in the original medicare fee-for- service program under parts A and B of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq., 1395j et seq.], the Medicare Advantage program under part C of such title [42 U.S.C. 1395w–21 et seq.], and any other programs under such title XVIII [42 U.S.C. 1395 et seq.]. ‘‘(c) AUTHORIZATION OF APPROPRIATIONS.—There are authorized to be appropriated such sums as may be nec- essary for purposes of conducting the evaluation and preparing the report required by this section.’’ GAO STUDY ON ACCESS TO PHYSICIANS’ SERVICES Pub. L. 108–173, title VI, § 604, Dec. 8, 2003, 117 Stat. 2301, provided that: ‘‘(a) STUDY.—The Comptroller General of the United States shall conduct a study on access of medicare beneficiaries to physicians’ services under the medicare program. The study shall include— ‘‘(1) an assessment of the use by beneficiaries of such services through an analysis of claims sub- mitted by physicians for such services under part B of the medicare program [42 U.S.C. 1395j et seq.]; ‘‘(2) an examination of changes in the use by bene- ficiaries of physicians’ services over time; and ‘‘(3) an examination of the extent to which physi- cians are not accepting new medicare beneficiaries as patients. ‘‘(b) REPORT.—Not later than 18 months after the date of the enactment of this Act [Dec. 8, 2003], the Comp- troller General shall submit to Congress a report on the study conducted under subsection (a). The report shall include a determination whether— ‘‘(1) data from claims submitted by physicians under part B of the medicare program [42 U.S.C. 1395j et seq.] indicate potential access problems for medi- care beneficiaries in certain geographic areas; and ‘‘(2) access by medicare beneficiaries to physicians’ services may have improved, remained constant, or deteriorated over time.’’ STUDY ON ENROLLMENT PROCEDURES FOR GROUPS THAT RETAIN INDEPENDENT CONTRACTOR PHYSICIANS Pub. L. 106–554, § 1(a)(6) [title IV, § 413], Dec. 21, 2000, 114 Stat. 2763, 2763A–515, provided that: ‘‘(a) IN GENERAL.—The Comptroller General of the United States shall conduct a study of the current medicare enrollment process for groups that retain independent contractor physicians with particular em- phasis on hospital-based physicians, such as emergency department staffing groups. In conducting the evalua- tion, the Comptroller General shall consult with groups that retain independent contractor physicians and shall— ‘‘(1) review the issuance of individual medicare pro- vider numbers and the possible medicare program in- tegrity vulnerabilities of the current process; ‘‘(2) review direct and indirect costs associated with the current process incurred by the medicare pro- gram and groups that retain independent contractor physicians; ‘‘(3) assess the effect on program integrity by the enrollment of groups that retain independent con- tractor hospital-based physicians; and ‘‘(4) develop suggested procedures for the enroll- ment of these groups. ‘‘(b) REPORT.—Not later than 1 year after the date of the enactment of this Act [Dec. 21, 2000], the Comp- troller General shall submit to Congress a report on the study conducted under subsection (a).’’ GAO STUDIES AND REPORTS ON MEDICARE PAYMENTS Pub. L. 106–554, § 1(a)(6) [title IV, § 437], Dec. 21, 2000, 114 Stat. 2763, 2763A–527, provided that: ‘‘(a) GAO STUDY ON HCFA POST-PAYMENT AUDIT PROCESS.— ‘‘(1) STUDY.—The Comptroller General of the United States shall conduct a study on the post-payment audit process under the medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] as such process applies to physicians, including the proper level of resources that the Health Care Fi- nancing Administration should devote to educating physicians regarding— ‘‘(A) coding and billing; ‘‘(B) documentation requirements; and ‘‘(C) the calculation of overpayments. ‘‘(2) REPORT.—Not later than 18 months after the date of the enactment of this Act [Dec. 21, 2000], the Comptroller General shall submit to Congress a re- port on the study conducted under paragraph (1) to- gether with specific recommendations for changes or improvements in the post-payment audit process de- scribed in such paragraph. Page 3708 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395ll ‘‘(b) GAO STUDY ON ADMINISTRATION AND OVER- SIGHT.— ‘‘(1) STUDY.—The Comptroller General of the United States shall conduct a study on the aggregate effects of regulatory, audit, oversight, and paperwork bur- dens on physicians and other health care providers participating in the medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.]. ‘‘(2) REPORT.—Not later than 18 months after the date of the enactment of this Act [Dec. 21, 2000], the Comptroller General shall submit to Congress a re- port on the study conducted under paragraph (1) to- gether with recommendations regarding any area in which— ‘‘(A) a reduction in paperwork, an ease of admin- istration, or an appropriate change in oversight and review may be accomplished; or ‘‘(B) additional payments or education are needed to assist physicians and other health care providers in understanding and complying with any legal or regulatory requirements.’’ STUDY AND REPORT REGARDING UTILIZATION OF PHYSICIANS’ SERVICES BY MEDICARE BENEFICIARIES Pub. L. 106–113, div. B, § 1000(a)(6) [title II, § 211(c)], Nov. 29, 1999, 113 Stat. 1536, 1501A–349, provided that: ‘‘(1) STUDY BY SECRETARY.—The Secretary of Health and Human Services, acting through the Administrator of the Agency for Health Care Policy and Research, shall conduct a study of the issues specified in para- graph (2). ‘‘(2) ISSUES TO BE STUDIED.—The issues specified in this paragraph are the following: ‘‘(A) The various methods for accurately estimating the economic impact on expenditures for physicians’ services under the original medicare fee-for-service program under parts A and B of title XVIII of the So- cial Security Act (42 U.S.C. 1395 et seq.) [42 U.S.C. 1395c et seq., 1395j et seq.] resulting from— ‘‘(i) improvements in medical capabilities; ‘‘(ii) advancements in scientific technology; ‘‘(iii) demographic changes in the types of medi- care beneficiaries that receive benefits under such program; and ‘‘(iv) geographic changes in locations where medi- care beneficiaries receive benefits under such pro- gram. ‘‘(B) The rate of usage of physicians’ services under the original medicare fee-for-service program under parts A and B of title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) among beneficiaries be- tween ages 65 and 74, 75 and 84, 85 and over, and dis- abled beneficiaries under age 65. ‘‘(C) Other factors that may be reliable predictors of beneficiary utilization of physicians’ services under the original medicare fee-for-service program under parts A and B of title XVIII of the Social Secu- rity Act (42 U.S.C. 1395 et seq.). ‘‘(3) REPORT TO CONGRESS.—Not later than 3 years after the date of the enactment of this Act [Nov. 29, 1999], the Secretary of Health and Human Services shall submit a report to Congress setting forth the results of the study conducted pursuant to paragraph (1), to- gether with any recommendations the Secretary deter- mines are appropriate. ‘‘(4) MEDPAC REPORT TO CONGRESS.—Not later than 180 days after the date of submission of the report under paragraph (3), the Medicare Payment Advisory Com- mission shall submit a report to Congress that in- cludes— ‘‘(A) an analysis and evaluation of the report sub- mitted under paragraph (3); and ‘‘(B) such recommendations as it determines are ap- propriate.’’ STUDY OF ADULT DAY CARE SERVICES Pub. L. 100–360, title II, § 208, July 1, 1988, 102 Stat. 732, as amended by Pub. L. 100–485, title VI, § 608(d)(8), Oct. 13, 1988, 102 Stat. 2415, directed Secretary of Health and Human Services to conduct a survey of adult day care services in United States and to report to Congress, by not later than 1 year after July 1, 1988, on the informa- tion collected in the survey, prior to repeal by Pub. L. 101–234, title II, § 201(a), Dec. 13, 1989, 103 Stat. 1981. STUDY TO DEVELOP A STRATEGY FOR QUALITY REVIEW AND ASSURANCE Pub. L. 99–509, title IX, § 9313(d), Oct. 21, 1986, 100 Stat. 2004, as amended by Pub. L. 100–203, title IV, § 4085(i)(21)(A), Dec. 22, 1987, 101 Stat. 1330–133, directed Secretary of Health and Human Services to arrange, with the National Academy of Sciences or other appro- priate nonprofit private entity, for a study to design a strategy for reviewing and assuring the quality of care for which payment may be made under this subchapter, specified items to be included in the study, and di- rected Secretary to submit to Congress, not later than Jan. 1, 1990, a report on the study with recommenda- tions with respect to strengthening quality assurances and review activities for services furnished under the medicare program. SPECIAL TREATMENT OF STATES FORMERLY UNDER WAIVER For treatment of hospitals in States which have had a waiver approved under this section, upon termination of waiver, see section 9202(j) of Pub. L. 99–272, as amended, set out as a note under section 1395ww of this title. DRUG DETOXIFICATION MEDICARE COVERAGE AND FACILITY INCENTIVES Pub. L. 96–499, title IX, § 931(f), Dec. 5, 1980, 94 Stat. 2634, which related to a study of medicare coverage of certain additional detoxification-related services, was repealed by Pub. L. 97–35, title XXI, § 2121(h), Aug. 13, 1981, 95 Stat. 796. LEGISLATIVE RECOMMENDATIONS REGARDING REIMBURSEMENT FOR OPTOMETRISTS’ SERVICES Pub. L. 96–499, title IX, § 937(b), Dec. 5, 1980, 94 Stat. 2640, provided that the Secretary of Health and Human Services submit to the Congress by Jan. 1, 1982, legisla- tive recommendations with respect to reimbursement under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.] for services furnished by optometrists in connection with cataracts and such other services which they are legally authorized to perform. DEMONSTRATION PROJECTS, STUDIES, AND REPORTS: NUTRITIONAL THERAPY, SECOND OPINION COST-SHAR- ING, SERVICES OF REGISTERED DIETITIANS, SERVICES OF CLINICAL SOCIAL WORKERS, ORTHOPEDIC SHOES, RESPIRATORY THERAPY SERVICES, AND FOOT CONDI- TIONS; GRANTS, PAYMENTS, AND EXPENDITURES Pub. L. 96–499, title IX, § 958, Dec. 5, 1980, 94 Stat. 2648, directed Secretary of Health and Human Services to carry out certain demonstration projects and conduct certain studies as follows: (a) a demonstration project to determine extent to which nutritional therapy in early renal failure could retard the disease with result- ant substantive deferment of dialysis, and aspects of making such therapy available under this subchapter, report to Congress to be submitted within twenty-four months of Dec. 5, 1980; (b) demonstration projects with respect to waiving the applicable cost sharing amounts which beneficiaries under this subchapter had to pay for obtaining a second opinion on having surgery, re- port to be submitted within one year after Dec. 5, 1980; (c) a study of conditions under which services of reg- istered dietitians could be covered as a home health benefit under this subchapter, report to be submitted within twenty-four months of Dec. 5, 1980; (d) dem- onstration projects to determine aspects of making services of clinical social workers more generally avail- able under this subchapter, report to be submitted within twenty-four months of Dec. 5, 1980; (e) a study of Page 3709 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395mm methods for providing coverage under part B of this subchapter for orthopedic shoes for individuals with disabling or deforming conditions requiring special fit- ting considerations, or requiring special shoes in con- junction with the use of an orthosis or foot support, re- port to be submitted no later than July 1, 1981; (f) a study of conditions under which services with respect to respiratory therapy could be covered as a home health benefit under this subchapter, report to be sub- mitted within twenty-four months of Dec. 5, 1980; and (g) a study analyzing cost effects of alternative ap- proaches to improving coverage under this subchapter for treatment of various types of foot conditions, re- port to be submitted within twenty-four months of Dec. 5, 1980. Payments and expenditures for such studies and projects were to be made in appropriate part from the Federal Hospital Insurance Trust Fund established by section 1395i of this title, and the Federal Supple- mentary Medical Insurance Trust Fund established by section 1395t of this title. DEMONSTRATION PROJECT RELATING TO THE TERMINALLY ILL Pub. L. 96–265, title V, § 506, June 9, 1980, 94 Stat. 475, authorized Secretary of Health and Human Services to provide for participation, by Social Security Adminis- tration, in a demonstration project relating to the ter- minally ill then being conducted within the Depart- ment of Health and Human Services, the purpose of such participation to be to study impact on terminally ill of provisions of disability programs administered by Social Security Administration and to determine how best to provide services needed by persons who were terminally ill through programs over which the Social Security Administration had administrative responsi- bility, and authorized to be appropriated necessary sums not in excess of $2,000,000 for any fiscal year. REPORT TO CONGRESS WITH RESPECT TO URBAN OR RURAL COMPREHENSIVE MENTAL HEALTH CENTERS AND CENTERS FOR TREATMENT OF ALCOHOLISM AND DRUG ABUSE; SUBMISSION NO LATER THAN JUNE 13, 1978 Pub. L. 95–210, § 4, Dec. 13, 1977, 91 Stat. 1490, directed Secretary of Health, Education, and Welfare to submit to Congress, no later than six months after Dec. 13, 1977, a report on the advantages and disadvantages of extending coverage under this subchapter to urban or rural comprehensive mental health centers and to cen- ters for treatment of alcoholism and drug abuse. STUDY AND REVIEW BY COMPTROLLER GENERAL OF AD- MINISTRATIVE STRUCTURE FOR PROCESSING MEDICARE CLAIMS; REPORT TO CONGRESS Pub. L. 95–142, § 12, Oct. 25, 1977, 91 Stat. 1197, directed Comptroller General to conduct a comprehensive study and review of administrative structure established for processing of claims under this subchapter for purpose of determining whether and to what extent more effi- cient claims administration under this subchapter could be achieved and directed Comptroller General to submit to Congress no later than July 1, 1979, a com- plete report with respect to such study and review. REPORT BY SECRETARY OF HEALTH, EDUCATION, AND WELFARE ON DELIVERY OF HOME HEALTH AND OTHER IN-HOME SERVICES; CONTENTS; CONSULTATION RE- QUIREMENTS; SUBMISSION TO CONGRESS Pub. L. 95–142, § 18, Oct. 25, 1977, 91 Stat. 1202, directed Secretary of Health, Education, and Welfare, not later than one year after Oct. 25, 1977, to submit to appro- priate committees of Congress a report analyzing, eval- uating, and making recommendations with respect to all aspects of delivery of home health and other in- home services authorized to be provided under sub- chapters XVIII, XIX, and XX of this chapter. § 1395mm. Payments to health maintenance orga- nizations and competitive medical plans (a) Rates and adjustments (1)(A) The Secretary shall annually determine, and shall announce (in a manner intended to provide notice to interested parties) not later than September 7 before the calendar year con- cerned— (i) a per capita rate of payment for each class of individuals who are enrolled under this section with an eligible organization which has entered into a risk-sharing contract and who are entitled to benefits under part A and enrolled under part B, and (ii) a per capita rate of payment for each class of individuals who are so enrolled with such an organization and who are enrolled under part B only. For purposes of this section, the term ‘‘risk- sharing contract’’ means a contract entered into under subsection (g) and the term ‘‘reasonable cost reimbursement contract’’ means a contract entered into under subsection (h). (B) The Secretary shall define appropriate classes of members, based on age, disability sta- tus, and such other factors as the Secretary de- termines to be appropriate, so as to ensure actu- arial equivalence. The Secretary may add to, modify, or substitute for such classes, if such changes will improve the determination of actu- arial equivalence. (C) The annual per capita rate of payment for each such class shall be equal to 95 percent of the adjusted average per capita cost (as defined in paragraph (4)) for that class. (D) In the case of an eligible organization with a risk-sharing contract, the Secretary shall make monthly payments in advance and in ac- cordance with the rate determined under sub- paragraph (C) and except as provided in sub- section (g)(2), to the organization for each indi- vidual enrolled with the organization under this section. (E)(i) The amount of payment under this para- graph may be retroactively adjusted to take into account any difference between the actual number of individuals enrolled in the plan under this section and the number of such individuals estimated to be so enrolled in determining the amount of the advance payment. (ii)(I) Subject to subclause (II), the Secretary may make retroactive adjustments under clause (i) to take into account individuals enrolled dur- ing the period beginning on the date on which the individual enrolls with an eligible organiza- tion (which has a risk-sharing contract under this section) under a health benefit plan oper- ated, sponsored, or contributed to by the indi- vidual’s employer or former employer (or the employer or former employer of the individual’s spouse) and ending on the date on which the in- dividual is enrolled in the plan under this sec- tion, except that for purposes of making such retroactive adjustments under this clause, such period may not exceed 90 days. (II) No adjustment may be made under sub- clause (I) with respect to any individual who does not certify that the organization provided the individual with the explanation described in subsection (c)(3)(E) at the time the individual enrolled with the organization.