CFR > Title 42 - Public Health > CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES > SUBCHAPTER B—MEDICARE PROGRAM (parts 405 to 426) > PART 417—HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS > SUBPART P—Medicare Payment: Risk Basis (§417.580 to §417.598) > 417.597—Withdrawal from a benefit stabilization fund.

417.597—Withdrawal from a benefit stabilization fund.

(a) Notification to CMS. An HMO's or CMP's request to make a withdrawal from its benefit stabilization fund for use during a contract period must be made when the HMO or CMP notifies CMS of its ACR and its ACPRP for that contract period. In making its request, the HMO or CMP must—
(1) Indicate how it intends to use the withdrawn amounts;
(2) Justify the need for the withdrawal in terms of stabilizing the additional benefits it provides to Medicare enrollees;
(3) Document the HMO's or CMP's experience with fluctuations of revenue requirements relative to the additional benefits it provides to Medicare enrollees; and
(4) Document its experience during the contract period previous to the one for which it requests withdrawal to ensure that the HMO or CMP will not be using the withdrawn amounts to refinance losses suffered during that previous contract period.
(b) Criteria for CMS approval. CMS approves a request for a withdrawal from a benefit stabilization fund for use during the next contract period only if—
(1) The HMO's or CMP's average of its per capita rates of payment for the next contract period is less than that of the previous contract period;
(2) The HMO's or CMP's ACR for the next contract period is significantly higher than that of the previous contract period; or
(3) The HMO's or CMP's revenue requirements for the next contract period for providing the additional benefits it provided during the previous contract period is significantly higher than the requirements for that previous period and the ACR for the next contract period results in an additional benefits package that is less in total value than that of the previous contract period.
(c) Basis for denial. CMS does not approve a request for a withdrawal from a benefit stabilization fund if the withdrawal would allow the HMO or CMP to—
(1) Offer without charge the supplemental services it provides to its Medicare enrollees under the provisions of § 417.440 (b)(2) or (b)(3); or
(2) Refinance prior contract period losses or to avoid losses in the upcoming contract period.
(d) Form of payment. Payment of monies withdrawn from a benefit stabilization fund is made, in equal parts, as an additional amount to the monthly advance payment made to the HMO or CMP under § 417.584 during the period of the contract.
[58 FR 38075, July 15, 1993, as amended at 60 FR 46233, Sept. 6, 1995]