Medicare Managed Care Manual. Chapter 4. Benefits and

Medicare Managed Care Manual

Chapter 4 - Benefits and Beneficiary Protections

Table of Contents

(Rev. 121, Issued: 04-22-16)

Transmittals for Chapter 4

10 – Introduction

10.1 – General Requirements

10.2 – Basic Rule

10.2.1 – Inpatient Stay During Which Enrollment Ends

10.2.2 – Exceptions to Requirement for MA plans to Cover FFS Benefits

10.3 – Types of Benefits

10.4 – Hospice Coverage

10.5 – Federal Medicare Requirements Related to Uniform Benefits and Non-

Discrimination

10.5.1 – Uniformity

10.5.2 – Anti-Discrimination

10.5.3 – Review for Discrimination and Steering

10.5.4 – Confidentiality

10.6 – Multiple Plan Offerings and Benefit Caps

10.7 – Clinical Trials

10.7.1 – Payment for Services

10.7.2 – Payment for Investigational Device Exemption (IDE) Studies

10.7.3 – Payment for Clinical Studies Approved Under Coverage with

Evidence

10.7.4 – Claims Processing Instructions for Clinical Studies

10.8 – Drugs Covered Under Original Medicare Part B

10.9 – Return to Enrollee’s Home Skilled Nursing Facility (SNF)

10.10 – Therapy Caps and Exceptions

10.11 – Transplant Services

10.12 – Durable Medical Equipment, Prosthetics, Orthotics and Supplies

10.12.1 – Designation of DME Providers/Suppliers

10.12.2 – Specifying Brands or Manufacturers of DME

10.12.3 – Brands/Manufacturers of DME not Subject to Limitation

10.12.4 – Prosthetics and Orthotics

10.12.5 – DMEPOS Competitive Bid Program

10.13 – Skilled Nursing Facility (SNF) Coverage

10.14 – No Dollar Limits on Provision of Part B Drugs

10.15 – Part D Rules for MA Plans

10.16 – Medical Necessity

20 – Ambulance, Emergency, Urgently Needed and Post-Stabilization

20.1 – Ambulance Services

20.2 – Definitions of Emergency and Urgently Needed Services

20.3 – MAO Responsibilities for Coverage of Emergency Services

20.4 – Stabilization of an Emergency Medical Condition

20.5 – Post-Stabilization Care Services

20.5.1 – Definition of Post-Stabilization

20.5.2 – MAO Financial Responsibility

20.5.3 – End of Post-Stabilization

20.5.4 – Cost-Sharing

30 – Supplemental Benefits

30.1 – Definition of Supplemental Benefit

30.2 – Supplemental Benefits Extending Original Medicare Benefits

30.3 – Examples of Eligible Supplemental Benefits

30.4 – Items and Services Not Eligible as Supplemental Benefits

40 – Over-the-Counter (OTC) Benefits

40.1 – Overview of OTC Benefit

40.2 – Access to OTC Benefits

40.3 – Payment Methods

40.3.1 – Special Rules for Manual Reimbursement

40.4 – Items and Their OTC Status

50 – Cost-sharing Guidance

50.1 – Guidance on Acceptable Cost-sharing

50.2 – Cost-sharing for In Network Preventive Services

50.3 – Total Beneficiary Cost (TBC)

50.4 – Single Deductible Rules for Regional and Local PPOs

50.5 – Guidance on Other Enrollee Out-of-Pocket Liability

50.6 – Cost Sharing for Dual-Eligible Enrollees Requiring an Institutional

Level of Care

60 – Meaningful Difference

70 – Non-Renewal Based on Low Enrollment

80 – Value-Added Items and Services (VAIS)

80.1 – Definition and Requirements

80.2 – Explanatory Examples

90 – National and Local Coverage Determinations

90.1 – Overview

90.2 – Definitions Related to National Coverage Determinations (NCDs)

90.3 – General Rules for NCDs

90.3.1 – When the Significant Cost Criterion is Not Met

90.3.2 – When the Significant Cost Criterion is Met

90.3.3 – Payment for NCD Items and Services

90.4 – Local Coverage Determinations (LCDs)

90.4.1 – MAC with Exclusive Jurisdiction over a Medicare Item or

Service

90.4.2 – Multiple A/B MACs with Different Policies

90.5 – Creating New Guidance

90.6 – Sources for Obtaining Information

100 – Rewards and Incentives

100.1 – Health Related Services and Activities

100.2 – Non-discrimination

100.3 – Offering Rewards In Connection With the Entire Service or Activity

100.4 – Valuing Rewards and Incentives

100.5 – Permissible Rewards and Incentives

100.6 – Marketing RI Programs

100.7 – Reporting to CMS

110 – Access to and Availability of Services

110.1 – Access and Availability Rules for Coordinated Care Plans

110.1.1 – Provider Network Standards

110.1.2 – Significant Changes to Networks

110.1.2.1 – General

110.1.2.2 – Notification to CMS

110.1.2.3 – Notification to Enrollees

110.1.2.4 – MAO/Provider Notification

110.1.2.5 – Significant Network Change Special Election Period

(SEP)

110.1.3 – Services for Which MA Plans Must Pay Non-contracted

110.2 – Provider Directories

110.2.1 – General

110.2.2 – Provider Directory Updates

110.2.3 – Provider Directory Dissemination and Timing

110.2.4 – Online Provider Directory Requirements

110.2.5 – Provider Directory Disclaimers

110.2.6 – Provider Directory Submission to CMS

110.3 – Health Maintenance Organization (HMO) and HMO Point of Service

(POS) Coverage and Access

110.4 – Preferred Provider Organization (PPO) Coverage and Access

110.5 – Special Rules for RPPOs

110.5.1 – Access through Non-contracted Providers

110.5.2 – Essential Hospitals

110.6 – Ensuring Coordination of Care

110.7 – Access, Gatekeeper and Cost-Sharing by Plan Type

120 – Coordination of Medicare Benefits with Employer/Union Group

120.1 – General Rule

120.2 – Requirements, Rights, and Beneficiary Protections

120.3 – Employer/Union Plans

130 – Medicare Secondary Payer (MSP) Procedures

130.1 – Basic Rule

130.2 – Responsibilities of the MAO

130.3 – Medicare Benefits Secondary to Group Health Plans (GHPs) and Large

Group Health Plans (LGHPs) and in Settlements

130.4 – Collecting From Other Entities

130.5 – Collecting From Other Insurers or the Enrollee

130.6 – Collecting From Group Health Plans (GHPs) and Large Groups

130.7 – Medicare as Secondary Payer (MSP) Rules and State Laws

140 – Service Area

140.1 – Service Area Defined

140.2 – Factors That Influence Service Area Approvals

140.3 – Partial County Service Areas

140.3.1 – Necessity

140.3.2 – Non-Discriminatory

140.3.3 – Best Interests of Beneficiaries

150 – Benefits during Disasters and Catastrophic Events

160 – Beneficiary Protections Related to Plan-Directed Care

170 – Balance Billing

170.1 – Definitions

170.2 – Balance Billing by Provider Type

180 – Information on Advance Directives

180.1 – Definition

180.2 – Basic Rule

180.3 – State Law Primary

180.4 – Content of Enrollee Information and Other MA Obligations

180.5 – Incapacitated Enrollees

180.6 – Community Education Requirements

180.7 – MAO Rights

180.8 – Anti-discrimination Rights

190 – Part C Explanation of Benefits (EOB)

200 – Educating and Enrolling Members in Medicaid and Medicare Savings

200.1 – Defining Guidance

200.2 – Relationship to D-SNP Eligibility/Enrollment

200.3 – Relationship to Dual Eligible Demonstration Programs

200.4 – Scope of Financial Assistance Programs

200.5 – Targeting Membership

200.6 – Required Elements of Education/Enrollment Assistance Programs

200.7 – CMS Oversight

PART I: BENEFITS

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Part I of this chapter provides key information for Medicare Advantage Organizations

(MAOs) regarding Medicare Advantage (MA) benefits for use in designing Plan Benefit

Packages (PBP). Part II of this chapter, which begins at section 110, provides

information on beneficiary protections, and includes topics such as rules for plan

renewals, coordination of benefits, and educating and enrolling individuals in Medicaid

and Medicare Savings Programs.

10 – Introduction

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

10.1 – General Requirements

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

These guidelines reflect CMS’ current interpretation of the provisions of the Medicare

Advantage statute and regulations (chapter 42 of the Code of Federal Regulations, part

422) pertaining to benefits and beneficiary protections. This guidance is subject to

change as technology and industry practices in plan design and administration evolve and

as CMS gains additional experience administering the MA program.

This chapter is governed by regulations set forth at 42 CFR 422, Subpart C, and is

generally limited to the benefits offered under Medicare Part C of the Social Security

Act. Guidance on cost plans may be found in Subpart F of chapter 17 of the Medicare

Managed Care Manual (MMCM). Guidance on Part D requirements may be found in the

Prescription Drug Benefit Manual located at: http://www.cms.gov/Medicare/Prescription-

Drug-Coverage/PrescriptionDrugCovContra/PartDManuals.html. Part D prescription

drug coverage is defined at 42 CFR 423.100 and in chapter 5 of the Prescription Drug

Benefit Manual.

10.2 – Basic Rule

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

An MAO offering an MA plan must provide enrollees in that plan with all Part A and Part

B original Medicare services, if the enrollee is entitled to benefits under both parts, and

Part B services if the enrollee is a grandfathered “Part B only” enrollee. The MAO fulfills

its obligation of providing original Medicare benefits by furnishing the benefits directly,

through arrangements, or by paying for the benefits on behalf of enrollees.

Basic benefits must be furnished through providers meeting requirements that are

specified at 42 CFR §422.204(b)(3) and discussed more fully in chapter 6 of this manual,

“Relationships with Providers,” which may be found at:

http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/mc86c06.pdf.

Administration of the Medicare program is governed by title XVIII of the Social Security

Act (the Act). Under the Medicare program, the scope of benefits available to eligible

beneficiaries is prescribed by law and divided into several main parts. Part A is the

hospital insurance program and Part B is the voluntary supplementary medical insurance

program.

The scope of the benefits under Part A and Part B is defined in the Act. Part A and Part B

benefits are discussed in sections 1812 and 1832 of the Act, respectively, while section

1861 of the Act lays out the definition of medical and other health services. Specific

health care services must fit into one of these benefit categories, and not be otherwise

excluded from coverage under the Medicare program (see §1862 for exclusions).

In general, the Act lists categories of items and services covered by Medicare, although

Congress occasionally adds specific services to be covered by Medicare. Some categories

are defined more broadly than others; for example, the Act includes hospital outpatient

services furnished incident to physicians’ services (§1861(s)(2)(B)) but also specifically

includes diabetes screening tests (§1861(s)(2)(Y)). The Secretary has the authority to

make determinations about which specific items and services, within categories, may be

covered under the Medicare program. Further interpretation is provided in the Code of

Federal Regulations and CMS guidance.

In general, Medicare coverage and payment is contingent upon a determination that:

• A service is in a covered benefit category;

• A service is not specifically excluded from Medicare coverage by the Act; and

• The item or service is “reasonable and necessary” for the diagnosis or treatment of an

illness or injury, to improve functioning of a malformed body member, or is a

covered preventive service.

These criteria are codified through rulemaking in the Code of Federal Regulations and/or

applied in manual guidance, or are applied through coverage determinations (see section

90 of this chapter). In addition, beneficiaries under part B are entitled to receive an

“annual wellness visit,” certain preventive services for which no cost-sharing may be

charged, and additional preventive services.

Several original Medicare covered benefits and services are covered only for specific

benefit periods, e.g., inpatient hospital services, skilled nursing facility services, and

inpatient psychiatric hospital services. While an MA plan may offer additional coverage

as a supplemental benefit, it may not limit the original Medicare coverage.

MA plans must provide their enrollees with all basic benefits covered under original

Medicare. Consequently, plans may not impose limitations, waiting periods or exclusions

from coverage due to pre-existing conditions that are not present in original Medicare.

The following requirements apply with respect to the rule that MAOs must cover the

costs of original Medicare benefits:

• Benefits: MA plans must provide or pay for medically necessary Part A (for those

entitled) and Part B covered items and services.

• Access: MA enrollees must have access to all medically necessary Part A and Part B

services. However, MA plans are not required to provide MA enrollees the same

access to providers that is provided under original Medicare (see accessibility rules

for MA plans under section 110 of this chapter).

• Cost-Sharing: With the exception of the services listed at 42 CFR 422.100(j) and

certain preventive services graded A or B by the United States Preventive Services

Task Force and covered by original Medicare without cost-sharing (co-insurance),

MA plans may impose cost-sharing for a particular item or service that is above or

below the original Medicare cost-sharing for that service, provided the overall cost-

sharing under the plan is actuarially equivalent to that under original Medicare and

the plan cost-sharing structure does not discriminate against sicker beneficiaries, as

discussed in sections 10.5.2 and 10.5.3 of this chapter. MA plans may require

enrollees to pay higher cost-sharing amounts for services furnished out-of-network.

• Billing and Payment: MA plans need not follow original Medicare claims processing

procedures. MA plans may create their own billing and payment procedures as long

as providers – whether contracted or not – are paid accurately, timely and with an

audit trail. MA plans may not require enrollees to pay providers – whether contracted

or not – for original Medicare services and then be reimbursed by the plan. See

section 110.1.3 of this chapter for rules governing payment to non-contracted

providers for original Medicare non-emergent services.

10.2.1 – Inpatient Stay During Which Enrollment Ends

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

MAOs must continue to cover, through discharge, inpatient services of a non-plan

enrollee if the individual was an enrollee at the beginning of the inpatient stay. Note that

incurred non-inpatient services are paid by original Medicare or the new MAO the

enrollee joined as of the effective date of the new coverage.

Enrollee cost-sharing for the inpatient hospital stay is based on the cost-sharing amounts

as of the entry date into the hospital.

If the enrollee is in a SNF in December and in an MAO that does not require a prior

qualifying 3-day hospital stay and then joins original Medicare on January 1, the stay

continues to be considered a covered stay (if medically required).

10.2.2 – Exceptions to Requirement for MA plans to Cover FFS Benefits

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The following circumstances are exceptions to the rule that MAOs must cover the costs

of original Medicare benefits:

• Hospice: Original Medicare (rather than the MAO) will pay the hospice for the

services received by an enrollee who has elected hospice while enrolled in the plan.

For detailed information about services furnished to an enrollee who has elected

hospice care, see section 10.4 below.

• Clinical trials: Original Medicare pays for the costs of routine services provided to an

MA enrollee who joins a qualifying clinical trial. MA plans pay the enrollee the

difference between original Medicare cost-sharing incurred for qualifying clinical

trial items and services and the MA plan’s in-network cost-sharing for the same

category of items and services. For further information on coverage and payment of

clinical trials in MA plans, see section 10.7 below.

• Inpatient stay during which MA enrollment begins: (42 CFR § 422.318) If a Medicare

beneficiary is in an inpatient stay and his enrollment in an MA plan takes effect after

the stay begins, but prior to discharge from that stay:

o Original Medicare is responsible for the costs of that inpatient stay; and

o The beneficiary is responsible for payment of cost-sharing as required under

original Medicare.

In addition to providing original Medicare benefits, the MAO also must furnish, arrange,

or pay for supplemental benefits and prescription drug benefits covered under the plan.

CMS reviews and approves an MAO’s coverage of benefits by ensuring compliance with

requirements described in this manual, including those outlined in this chapter, chapter 8,

“Payments to Medicare Advantage Organizations,” and other applicable CMS guidance,

such as that contained in the annual Call Letter.

10.3 – Types of Benefits

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Basic benefits: All MA plans must offer and identify in plan bids all medically necessary

Medicare Part A and Part B services, including Part B prescription drugs, as basic

benefits.

Part D prescription drug benefits: MA plans may choose to offer Part D benefits as

described at 42 CFR §423 and in chapter 5 of the Prescription Drug Benefit Manual.

Supplemental benefits: MA plans may choose to offer some benefits to enrollees in

addition to the covered Medicare Part A and Part B (and Part D, as applicable) benefits

they are required to offer if the item or service also meets the criteria described in

sections 30 and 40 of this chapter.

Supplemental benefits are further classified as either mandatory or optional:

Mandatory supplemental benefits are benefits not covered under Part A, Part B, or Part

D but are covered by the MAO for every person enrolled in the MA plan. Mandatory

supplemental benefits are paid for either in full, directly by, or on behalf of, MA enrollees

by premiums and cost-sharing, or through the application of rebate dollars. MAOs may

not impose waiting periods on mandatory supplemental benefits. An MA Medical Savings

Account (MSA) plan may not provide mandatory supplemental benefits.

Optional supplemental benefits are benefits not covered under Part A, Part B, or Part D,

but are offered uniformly to all enrollees. Enrollees may choose to pay extra to receive

coverage under the optional supplemental benefit. The optional supplemental benefit is

paid for directly by the enrollee or on behalf of the enrollee through an additional

premium and cost-sharing. MA plans may offer their enrollees a group of services as one

optional supplemental benefit, offer optional supplemental services individually, or offer

a combination of group and individual optional supplemental services. MA plan enrollees

choose whether to elect and pay for any particular optional supplemental benefit offered

under the MA plan.

Rebate dollars may not be applied toward optional supplemental benefits. An MA plan

may not offer as an optional supplemental benefit reduced cost-sharing for original

Medicare benefits (42 CFR §422.102(a)(4)). An MA plan may not list a dual eligible

beneficiary’s State Medicaid wraparound benefits as either a mandatory or optional

supplemental benefit.

MA MSA plans are permitted to offer optional supplemental benefits, provided that the

MSA plan does not offer an optional supplemental benefit that covers expenses that count

toward the annual MSA deductible.

Optional supplemental benefits must be offered: (1) at the beginning of the contract year

to all MA plan enrollees and (2) at the time of initial enrollment to new enrollees who

enroll during the contract year.

The MA plan may then:

• Continuously offer each optional supplemental benefit uniformly to all enrollees for

the remainder of the contract year; or

• Choose to place a time limit of at least 30 consecutive days starting from the enrollee

effective date during which a new enrollee can select any particular optional

supplemental benefit offered by the MA plan. After the enrollee’s 30-day selection

period ends, the optional benefits may be closed to that enrollee for the rest of that

contract year during which the beneficiary remains continuously enrolled.

Although MA plans may limit the availability of optional supplemental benefits to current

enrollees as described above, enrollees may voluntarily drop or discontinue optional

supplemental benefits at any time during the contract year upon proper advance notice to

the MA plan. An enrollee who drops an optional supplemental benefit through proper

advance notice as determined by the MAO, typically 30 days, need not pay further

monthly premiums for the optional supplemental benefit. Furthermore, if s/he paid a

complete annual premium for the optional supplemental benefit, s/he is entitled to a pro-

rated refund of unpaid premium for the remaining portion of the year.

Chapter 2 of the MMCM, “Enrollment and Disenrollment,” linked at

http://www.cms.gov/Medicare/Eligibility-and-

Enrollment/MedicareMangCareEligEnrol/index.html?redirect=/MedicareMangCareElig

Enrol/, provides the requirements for an involuntary disenrollment of an enrollee from an

MA plan when that enrollee fails to make timely payments of premium for optional

supplemental benefits.

MA plans may impose waiting periods for optional supplemental benefits that require

enrollees to have the specified coverage for a period of time before utilization. However,

MA plans that choose to impose waiting periods must describe the details, including the

length of the waiting period, in their annual bid as well as include the information in any

relevant marketing materials.

10.4 – Hospice Coverage

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

As defined in 42 CFR §422.320, MA plans must inform each enrollee eligible for hospice

care about its availability. This is true whether a Medicare hospice program is located

within the plan's service area or if it is common practice to refer patients to hospice

programs outside the plan’s service area.

An MA enrollee who elects hospice care, but chooses not to disenroll from the plan, is

entitled to continue to receive through the plan any MA benefits other than those that are

the responsibility of the hospice. Under such circumstances, the MA plan is paid a

reduced capitation rate for that enrollee by CMS and the MA plan is responsible for

continued coverage of supplemental benefits. CMS pays: (a) the hospice program for

hospice care furnished to the enrollee and (b) the MA plan, providers, and suppliers for

other Medicare-covered services furnished to the enrollee through the original Medicare

program, subject to the usual rules of payment.

Hospice coverage is effective immediately on the date of election; the reduced rate paid

to the MA plan begins the next month (42 CFR §422.320).

Table I below summarizes the cost-sharing and provider payments for services furnished

to an MA plan enrollee who elects hospice.

Table I: Payments for Services Furnished to an Enrollee who has Elected Hospice

Type of Services

Enrollee Coverage

Choice

Enrollee Cost-sharing

Payments to

Providers

Hospice program Hospice program

Original Medicare cost-

sharing

Original

Medicare

Non-hospice care

, Parts

A & B

MA plan or original

Medicare

MA plan cost-sharing,

if enrollee follows MA

plan rules

Original

Medicare

Original Medicare cost-

sharing, if enrollee

does not follow MA

plan rules

Original

Medicare

Non-hospice care

, Part

MA plan (if

applicable)

MA plan cost-sharing MAO

Supplemental

MA plan

MA plan cost-sharing

MAO

Notes:

1) The term ‘hospice care’ refers to original Medicare items and services related to the

terminal illness for which the enrollee entered the hospice. The term ‘non-hospice

care’ refers either to services not covered by original Medicare or to services not

related to the terminal condition for which the enrollee entered the hospice.

2) If the enrollee chooses original Medicare for coverage of covered, non-hospice-care,

original Medicare services and also follows MA plan requirements, then, the

enrollee pays plan cost-sharing and original Medicare pays the provider. The MA

plan must pay the provider the difference between original Medicare cost-sharing

and plan cost-sharing, if applicable.

3) An HMO enrollee who chooses to receive services out of network has not followed

plan rules and therefore is responsible to pay FFS cost-sharing; a PPO enrollee who

receives services out of network has followed plan rules and is only responsible for

plan cost-sharing. The enrollee need not communicate to the plan in advance his/her

choice of where services are obtained.

Please see the following resources for additional information:

• The Social Security Act, section 1853(h)(2)(B); and

• The Medicare Claims Processing Manual, chapter 11 - Processing Hospice Claims,

section 30.4

10.5 – Federal Medicare Requirements Related to Uniform Benefits and

Non-Discrimination

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

10.5.1 – Uniformity

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The following rules apply to any MA plan, regardless of plan type, and to any category of

benefit – basic, mandatory supplemental, and optional supplemental.

• All plan benefits must be offered uniformly to all enrollees residing in the service

area of the plan;

• When an MA plan has an authorized service area with one or more approved

segments, as defined in 42 CFR §422.2, the MA plan may vary premiums and cost-

sharing by segment, but the premium and cost-sharing must be uniform within each

segment. Furthermore, plan benefits must be uniformly provided throughout the

authorized service area of the plan, including any segments in the service area;

• The uniform premium requirement prohibits plans from offering nominal discounts to

those enrollees electing to pay premiums electronically;

• All plans must offer to, but may not require of, their enrollees:

o The option of having their premiums deducted from their Social Security check or

benefit;

o The option of having their premiums paid by an electronic transfer mechanism

(such as automatic charges of an account at a financial institution or a credit or

debit card account); and

o The option of paying their premium by check.

10.5.2 – Anti-Discrimination

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

An MAO may not deny, limit, or condition enrollment to individuals eligible to enroll in

an MA plan offered by the organization on the basis of any factor that is related to health

status, including, but not limited to the following:

• Claims experience;

• Receipt of health care;

• Medical history and medical condition including physical and mental illness;

• Genetic information;

• Evidence of insurability, including conditions arising out of acts of domestic

violence; or

• Disability.

Additionally, an MAO must:

• Comply with the provisions of section 1557 of the Affordable Care Act, title VI of the

Civil Rights Act of 1964, the Age Discrimination Act of 1975, section 504 of the

Rehabilitation Act of 1973, title II of the Americans with Disabilities Act (ADA) of

1990, and the Genetic Information Nondiscrimination Act of 2008; and

• Have procedures in place for each of its MA plans to ensure that enrollees are not

discriminated against in the delivery of health care services, consistent with the

benefits covered in their policy, based on race, ethnicity, national origin, religion,

gender, age, mental or physical disability, sexual orientation, genetic information, or

source of payment. Discrimination based on “source of payment” means, for

example, that MA providers cannot refuse to serve enrollees because they receive

assistance with Medicare cost-sharing from a State Medicaid program.

However, there are three situations in which enrollment in an MA plan may be denied

based on the presence or absence of a medical condition:

• To a person who does not fulfill the eligibility criteria for enrollment in a Special

Needs Plan (SNP), under the circumstances mentioned in chapter 16b of the MMCM,

“Special Needs Plans,” at:https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/mc86c16b.pdf;

• To a person with end-stage renal disease (ESRD), under the circumstances mentioned

in chapter 2 of the MMCM, “Enrollment and Disenrollment,” at:

http://www.cms.gov/Medicare/Eligibility-and-

Enrollment/MedicareMangCareEligEnrol/index.html?redirect=/MedicareMangCareEl

igEnrol/; and

• To a person receiving hospice benefits prior to completing an enrollment request for

an MSA plan. Refer to chapter 2 of the MMCM, “Enrollment and Disenrollment” at:

http://www.cms.gov/Medicare/Eligibility-and-

Enrollment/MedicareMangCareEligEnrol/index.html?redirect=/MedicareMangCareEl

igEnrol/

Additional information about Federal law and regulations related to discrimination may

be found at the following sites:

Age

HHS OCR Page on Age Discrimination

• http://www.hhs.gov/ocr/civilrights/understanding/age/index.html

Race, color, national origin

HHS OCR Page on Discrimination Based on Race, Color, and National Origin

• http://www.hhs.gov/ocr/civilrights/understanding/race/index.html

Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition

Against National Origin Discrimination Affecting Limited English Proficient Persons

• http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/hhslepguidancepdf.pdf

The National Culturally and Linguistically Appropriate Services (CLAS) Standards in

Health and Health Care

• http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15

Medical history/history of mental illness, claims experience, evidence of insurability,

genetic information

HHS Health Information Privacy Page

• http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/genetic/

DOL HIPPA Nondiscrimination Requirements

• http://www.dol.gov/ebsa/faqs/faq_hipaa_ND.html

Disability

HHS OCR Page on Disability Rights

• http://www.hhs.gov/ocr/civilrights/understanding/disability/

Medicare Page on Resources for People with Disabilities

• http://www.medicare.gov/people-like-me/disability/disability.html

DOJ Civil Rights Division Page on the Americans with Disabilities Act

• http://www.ada.gov/

Medicare Provider Applicants

HHS OCR Page on Medicare Provider Applicants

• http://www.hhs.gov/ocr/civilrights/clearance/index.html

10.5.3 – Review for Discrimination and Steering

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

CMS reviews and approves MA PBPs based on statutes, regulations, and policy

guidelines contained in this manual and other CMS instructions. Review is to ensure that:

• An MAO provides Medicare-covered services that meet CMS guidelines under

original Medicare;

• An MAO is responsible for how its downstream entities present the MAO, the MA

plan, and its benefits. If the downstream entity offers other items or services, not part

of the MA PBP, then they must not reference the MA plan or in any way characterize

such items or services as benefits covered or offered by the MA plan.

• An MAO does not offer a cost-sharing structure or plan benefits that:

o Condition eligibility for a supplemental benefit on utilization. For example, a

plan may not condition the offering of a gym benefit based on an enrollee

meeting minimal gym attendance requirements;

o Promote discrimination;

o Discourage enrollment;

o Encourage disenrollment;

o Steer specific subsets of Medicare beneficiaries to particular MA plans (with

the exception of SNPs);

o Inhibit access to services; and

o Design cost-sharing differentials in such a way as to unduly limit choice or

availability to the beneficiary. An MAO:

o May not, for example, charge higher copays for all providers in the

western portion of the county while charging lower co-payments for

providers in the eastern portion of the county;

o As indicated in section 50.1 below, must clearly disclose any tiered cost-

sharing to its enrollees; and

o May not design a plan with supplemental benefits that only appeal to

healthier beneficiaries.

o Benefit designs meet other MA program requirements.

Note: Section 50.1 below contains general guidance on acceptable cost-sharing. The anti-

discrimination prohibitions in this section apply to both original Medicare, mandatory

supplemental, and optional supplemental benefits.

An MAO must comply with all Federal laws and regulations designed to prevent or

ameliorate fraud, waste, and abuse including, but not limited to, applicable provisions of

the Federal criminal law, the False Claims Act (31 U.S.C. 3729 et seq.), the anti-kickback

statute (section 1128B(b)) of the Act, and HIPAA administrative simplification rules at

45 CFR parts 160, 162 and 164.

10.5.4 – Confidentiality

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs must establish procedures to ensure the confidentiality and accuracy of all

enrollee records, including medical records, as well as other health and enrollment

information the MAO maintains. MAOs must ensure that they:

• Abide by all Federal and state laws regarding confidentiality and disclosure of

medical records or other health and enrollment information, including the HIPAA

privacy rule at 45 CFR part 164 that require MAOs to report the loss of protected

health information without delay and, in cases affecting 500 or more individuals, no

later than 60 days after discovery.

• The MAO must safeguard the privacy of any information that identifies a particular

enrollee and have procedures that specify:

o For what purpose(s) the information will be used within the organization; and

o To whom and for what purpose(s) it will disclose the information outside the

organization;

• Ensure that medical information is released only in accordance with applicable

Federal or state law or pursuant to court orders or subpoenas;

• Maintain the records and information in an accurate and timely manner; and

• Ensure timely access by enrollees to the records and information that pertain to them.

For purposes of CMS audits of risk adjustment data, MAO network providers and

deemed contracted providers (of PFFS plans) must be required, under their contracts or

the plan’s Terms and Conditions of Payment, to provide medical records requested by the

MAO.

Medical records from providers also may be used by MAOs for the following purposes:

• Advance determinations of coverage;

• Plan coverage;

• Medical necessity;

• Proper billing;

• Quality reporting;

• Fraud and abuse investigations; and

• Plan initiated internal risk adjustment validation.

To encourage providers to submit enrollee medical records to the plan, an MAO may

choose to send staff to assist in the record collection or to reimburse providers for the

costs associated with furnishing the records. MAOs are prohibited from using medical

record reviews to delay payments to providers. Both required and voluntary provision of

medical records by providers must be consistent with HIPAA privacy statute and

regulations (http://www.hhs.gov/ocr/privacy/).

10.6- Multiple Plan Offerings and Benefit Caps

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

An MAO may offer more than one MA plan in the same service area (though each plan is

subject to the conditions and limitations established for the MA program). Caps for a

supplemental benefit can only be imposed at the MA plan level. For example, during a

contract year, if an enrollee switches to another MA plan offered by the same MAO in

the same service area, then an enrollee who has exhausted the supplemental benefit of

one plan is entitled to the full benefit of the other plan. This does not preclude MAOs

from providing benefits with periodic caps such as monthly or quarterly caps, so long as

general benefit standards, such as actuarial equivalence for basic benefits and compliance

with anti-discrimination provisions, are met.

10.7 – Clinical Trials

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

10.7.1 – Payment for Services

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

For clinical trials covered under the Clinical Trials National Coverage Determination

310.1 (NCD) (NCD manual, Pub. 100-03, Part 4, section 310), original Medicare covers

the routine costs of qualifying clinical trials for all Medicare enrollees, including those

enrolled in MA plans, as well as reasonable and necessary items and services used to

diagnose and treat complications arising from participating in qualifying clinical trials.

All other original Medicare rules apply.

Refer to the Medicare Clinical Trial Policy at: http://www.cms.gov/medicare-coverage-

database/details/ncd-details.aspx?NCDId=1&ncdver=2&bc=BAABAAAAAAAA and

for more information on the definition of routine costs and the clinical trial Medicare

qualification process. This policy does not withdraw Medicare coverage for items and

services that may be covered according to Local Coverage Determinations (LCDs) or the

regulations on category B investigational device exemptions (IDE) found in 42 CFR 405,

Subpart B, 411.15, and 411.406. MAOs may contact the Medicare Administrative

Contractor (MAC) for information about qualification and payment for clinical trial items

and services.

MAOs pay the enrollee the difference between original Medicare cost-sharing incurred

for qualified clinical trial items and services and the MA plan’s in-network cost-sharing

for the same category of items and services. This cost-sharing reduction requirement

applies to all qualifying clinical trials as defined in the NCD manual, Pub. 100-03, Part 4,

section 310.1. MAOs may not choose the clinical trial or clinical trial items and services

to which this policy applies. The MAO owes the difference even if the enrollee has not

yet paid the clinical trial provider. Additionally, the enrollee's in-network cost-sharing

portion also must be included in the plan’s out-of-pocket maximum calculation.

To be eligible for reimbursement, an enrollee (or providers acting on the enrollee’s

behalf) must notify their plan that the enrollee received a qualified clinical trial service

and provide documentation of the cost-sharing incurred, such as a provider bill. MAOs

also are permitted to seek the MA enrollee’s original Medicare cost-sharing information

directly from clinical trial providers.

MA enrollees are free to participate in any qualifying clinical trial that is open to

beneficiaries in original Medicare. If an MAO conducts its own clinical trial, the MAO

can explain to its enrollees the benefits of participating in its clinical trial; however, the

MAO may not require prior authorization for participation in a Medicare-qualified

clinical trial not sponsored by the plan, nor may it create impediments to an enrollee’s

participation in a non-plan-sponsored clinical trial, even if the MAO believes it is

sponsoring a clinical trial of a similar nature. Examples of impediments to an enrollee’s

participation include, but are not limited to, requiring enrollees to pay the original

Medicare cost-sharing amount for routine care services before being compensated by the

MAO for the difference or unduly delaying any required cost-sharing refund. Enrollees

retain the right to choose the clinical trial(s) in which they wish to participate. However,

an MAO may request, but not require, enrollees to notify the plan in advance when they

choose to participate in Medicare-qualified clinical trials.

10.7.2 – Payment for Investigational Device Exemption (IDE) Studies

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs are responsible for payment of claims related to enrollees’ participation in both

Category A and B IDE studies that are covered by the MAC with jurisdiction over the

MA plan’s service area. The MAO is responsible for payment of routine care items and

services in CMS-approved Category A and Category B IDE studies. The MAO is also

responsible for CMS-approved Category B devices. CMS will not approve Category A

devices because they are statutorily excluded from coverage.

CMS finalized changes to the IDE regulations (42 CFR § 405 Subpart B), effective

January 1, 2015. A listing of all CMS-approved Category A IDE studies and Category B

IDE studies will be posted on the CMS Coverage webpage site located at:

http://www.cms.hhs.gov/center/coverage.asp and published in the Federal Register.

10.7.3 – Payment for Clinical Studies Approved Under Coverage with

Evidence Development (CED)

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

In National Coverage Determinations (NCDs) requiring CED, Medicare covers items and

services in CMS-approved CED studies. MAOs are responsible for payment of items and

services in CMS-approved CED studies unless CMS determines that the significant cost

threshold is exceeded for that item or service (see 42 CFR 422.109). Approved CED

studies are posted on the CMS Coverage with Evidence Development webpage (see

http://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-

Development/index.html). Billing instructions are issued for each NCD.

10.7.4 – Claims Processing Instructions for Clinical Studies

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Complete requirements for claims processing and payment for clinical studies may be

found in the Medicare Claims Processing Manual, Transmittal 2955

(https://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/downloads/R2955CP.pdf).

10.8 – Drugs Covered Under Original Medicare Part B

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

For this subsection, the term “drug” means “drug or biological.” Drugs that are covered

under Medicare Part B are governed by original Medicare regulations and local coverage

decisions. For more coverage details, see the Medicare Benefits Policy Manual

Publication 100-02, chapter 15, section 50 “Drugs and Biologicals” and the Medicare

Claims Processing Manual, Publication 100-04, chapter 17, and sections of the Manual

referenced therein.

The following broad categories of drugs may be covered under Medicare Part B, subject

to coverage requirements and regulatory and statutory limitations. Note: These examples

are illustrative and do not comprise a comprehensive list.

• Injectable drugs that have been determined by MACs to be “not usually self-

administered” and are administered incident to physician services. For further

information, see the Medicare Policy Benefits Manual Publication 100-02, chapter

15, section 50.2 and 50.3.

• Drugs that are administered via durable medical equipment (such as nebulizers) that

were authorized by the enrollee’s MA plan.

• Drugs covered under Part B include, but are not limited to:

o Certain vaccines, including pneumococcal, hepatitis B (high or intermediate risk

only) influenza, and vaccines directly related to the treatment of an injury or

direct exposure to a disease or condition. For further details, see section 50.4.4.2

of chapter 15 of the Medicare Benefit Policy Manual accessible at

http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf;

o Certain oral anti-cancer drugs and anti-nausea drugs;

o Hemophilia clotting factors;

o Immunosuppressive drugs;

o Some antigens;

o Intravenous immune globulin administered in the home for the treatment of

primary immune deficiency;

o Injectable drugs used for the treatment of osteoporosis in limited situations; and

o Certain drugs, including erythropoietin, administered during the treatment of end-

stage renal disease.

If an MA enrollee wishes to receive a Part B covered drug in a physician’s office, then

the MAO must cover the drug and the service of administering the drug. MAOs may not

determine whether it was reasonable and necessary for the patient to choose to have his

or her Part B covered drug administered incident to physician services and may not

impose any uniform policy that prevents enrollees from having a Part B covered drug

administered in a physician’s office.

Injectable drugs that the applicable MAC has determined are not usually self-

administered, but that enrollees purchase at a pharmacy and administer at home may only

be offered by MAOs as a Part D benefit. However, MA enrollees always have the option

of receiving the Medicare-covered benefit, i.e., administration of the covered drug, in a

physician’s office from the physician’s stock of drugs.

Some drugs are covered under either Part B or Part D depending on the circumstances

and enrollees generally may not be denied Part D coverage of a drug based solely on its

availability under Part B. It is critical to understand when a drug is covered under Part

B or Part D in order to protect beneficiaries from coverage disruption and to ensure that

Part C and Part D bids properly reflect appropriate coverage under either Part B or

Part D. For detailed guidance and clarification on coverage under Part B versus Part D,

see Appendix C of chapter 6 of the Part D Prescription Drug Benefit Manual located at:

http://www.cms.gov/Medicare/Prescription-Drug-

Coverage/PrescriptionDrugCovContra/PartDManuals.html.

10.9 – Return to Enrollee’s Home Skilled Nursing Facility (SNF)

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

An MA plan must provide coverage through a home SNF (defined at 42 CFR

§422.133(b)) of post-hospital extended care services to enrollees who resided in a nursing

facility prior to the hospitalization, provided:

• The enrollee elects to receive the coverage through the home SNF; and

• The home SNF either has a contract with the MA plan or agrees to accept

substantially similar payment under the same terms and conditions that apply to

similar nursing facilities that contract with the MA plan.

This requirement also applies if the MA plan offers SNF care without requiring a prior

qualifying hospital stay.

The post-hospital extended care scope of services, cost-sharing, and access to coverage

provided by the home SNF must be no less favorable to the enrollee than post-hospital

extended care services coverage that would be provided to the enrollee by a SNF that

would be otherwise covered under the MA plan (42 CFR §422.133(c)). In a PPO, in-

network cost-sharing applies.

10.10 – Therapy Caps and Exceptions

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Certain services are exempted from original Medicare caps for rehabilitation services.

Complete details can be found in section 10.2 of chapter 5 of publication 100-04, the

Medicare Claims Processing Manual, at http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html.

10.11 – Transplant Services

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

As explained in section 10.2 above, MA plans must provide all original Medicare

services to its enrollees. For coordinated care plans, in-network transplant services may

be provided outside of the plan service area if the services are accessible and available to

enrollees, and that service delivery is consistent with community patterns of care for

original Medicare beneficiaries who reside in the same area.

MA plans, for reasons of cost (as explained below), may wish to provide a required

original Medicare transplant service at a distant location (further away than the normal

community patterns of care for that service), even though provision of the service is

available locally (within the service area), consistent with community patterns of care for

original Medicare beneficiaries who reside in the service area.

The MA plan’s provision of transplant services at a distant location, farther away than the

normal community patterns of care for transplant services, depends on the local cost of

transplants:

• If the local providers of transplants, within the normal community patterns of care for

transplants, are not willing to cover transplants for MA enrollees at a mutually agreed

upon payment rate, then the MA plan must offer transplants through alternative

transplant providers.

• If the local providers of transplants, within the normal community patterns of care for

transplants, are willing to cover transplants for MA enrollees at the original Medicare

rate or at a mutually agreed upon rate, then, although the MA plan may also offer

transplants at a more distant location, the MA plan must allow enrollees the option of

obtaining transplant services locally.

When providing an original Medicare service at a more distant location, farther away

than the normal community patterns of care for transplants, the MA plan must ensure that

the distant location provides at least the same quality and timeliness of services as at the

local providers of this service. More specifically, the transplant center at the distant

location must be a Medicare-eligible transplant provider and the waiting time for the

transplant should not be significantly longer than the waiting within the normal

community patterns of care.

In any circumstance in which an MA plan provides transplant services at a more distant

location, the MA plan must:

• Provide reasonable transportation for the enrollee and a companion to the distant

facility; and

• Provide reasonable accommodations for the enrollee and a companion while in the

distant location for medical care.

10.12 – Durable Medical Equipment, Prosthetics, Orthotics and

Supplies (DMEPOS)

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

MA plans are required to “provide coverage of, by furnishing, arranging for, or making

payment for, all services that are covered by Medicare Part A and Part B” (see 42 CFR

422.101(a)), which includes coverage of durable medical equipment, prosthetics and

supplies. The MAO is responsible for maintaining continuity of care for its enrollee by

ensuring uninterrupted access to the medically necessary covered DME item, including

when the item needs to be repaired or replaced. If necessary, the MAO must purchase or

rent a replacement item for the beneficiary to use.

10.12.1 – Designation of DME Providers/Suppliers

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

During the application process, MA plans identify specific DME suppliers with whom

they have a contract to provide enrollees with all medically necessary DME items and

supplies. MA plans are also expected to update provider/supplier directory information

any time they become aware of changes. All updates to the online directory are expected

to be done in real-time. For more information about provider directory requirements, see

section 110.2 below.

The plan may disclose information on the suppliers contracted to provide DME to

enrollees as an attachment to the Annual Notice of Change (ANOC) and the Evidence of

Coverage (EOC) and plans that limit the DME brands and manufacturers it will cover are

instructed to attach to the EOC or ANOC, as appropriate, a list of those brands and

manufacturers.

10.12.2 – Specifying Brands or Manufacturers of DME

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

MA plans may specify brands and manufacturers as preferred and charge lower cost-

sharing for the preferred brands or may limit the DME to only those preferred brands and

manufacturers, as long as the following conditions are met (42 CFR 422.100(l)):

• The MA plan provides all categories of DME covered under original Medicare Part

• The MA plan ensures that enrollees have access to all medically necessary (including

non-preferred) DME products or brands;

• The MA plan’s contracted suppliers provide access to all preferred DME brands;

• During an enrollee’s first year of enrollment in an MA plan, if the enrollee requests,

the plan will provide a 90-day transition period (commencing with the initial time of

enrollment) during which the plan provides (and repairs, as applicable) non-preferred

DME brands furnished in the previous year;

• Although the MA plan may add brands to its preferred formulary during the year, it

may not remove any brands mid-year;

• The MA plan treats denials of non-preferred DME products or brands as organization

determinations;

• The MA plan discloses DME coverage limitations and appeal rights in the case of a

denial of a non-preferred DME product or brand with the EOC and ANOC and on its

website; and

• The MA plan provides full coverage, without limitation on brand and manufacturer,

to DME categories or subcategories annually determined by CMS to require full

coverage.

10.12.3 – Brands/Manufacturers of DME not Subject to Limitation

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

Some DME items are not interchangeable, that is, they must be tailored to fit individual

enrollees. As a result, such items, as designated by CMS annually, will not be subject to

limitation based on brand or manufacturer or may not be limited under certain

circumstances. Up-to-date information is published annually in the Call Letter.

10.12.4 – Prosthetics and Orthotics

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

The MA plan must provide all brands and manufacturers of Prosthetics and Orthotics

without limitation.

10.12.5 – DMEPOS Competitive Bid Program

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

On January 1, 2011, the original Medicare payment amount for DMEPOS competitive

bid items furnished in Competitive Bidding Areas (CBAs) was reduced below the fee

schedule payment. The program only affects certain geographic areas and certain

categories of DMEPOS; exceptions may apply. For the latest guidance refer to

information at http://www.cms.gov/DMEPOSCompetitiveBid/. The program affects MA

payments in those situations when an MA plan is only required to pay at least the original

Medicare rate, for example, when reimbursing suppliers that are not under contract with

the MA plan. MAOs must disclose information on the new program to their plan

enrollees. MAOs should inform enrollees how the DMEPOS competitive bidding

program will affect them and what they should do if they need to change suppliers, for

example, in cases where an enrollee’s current supplier is not one of the “Medicare

contract suppliers” under the DMEPOS competitive bidding program and they cannot be

grandfathered under the DMEPOS competitive bidding program.

10.13 – Skilled Nursing Facility (SNF) Coverage

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

Prior to termination of SNF services, the provider must deliver a valid written notice to

the enrollee of the MAO’s decision to terminate covered services no later than two days

before the proposed end of the services (42 CFR § 422.624(b)). The MAO is financially

liable for continued services until two days after the enrollee receives valid notice. If the

enrollee’s services are expected to be fewer than two days in duration, the provider

should notify the enrollee at the time of admission to the provider. An enrollee who

receives advance notice and agrees with the termination of services earlier than 2 days

hence, may waive continuation of services.

10.14 – No Dollar Limits on Provision of Part B Drugs

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

No dollar limits may be placed on the provision of Part B drugs covered under original

Medicare unless the Medicare statute imposes the limit on original Medicare coverage, it

is specified in a national or applicable local coverage determination, or CMS imposes a

dollar limit. (See section 90.2 below for more detailed guidance on the obligation of plans

to follow local coverage determinations.)

10.15 – Part D Rules for MA Plans

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

As provided at 42 CFR §422.4(c), an MAO cannot offer an MA coordinated care plan in

an area unless that plan or another plan offered by the MAO in that same service area

includes Part D prescription drug coverage. Table II provides a summary of the basic

requirements for Part D coverage by MA plans. For complete information, please rely on

the Part D prescription drug coverage information provided in chapter 5 of the

Prescription Drug Benefit Manual.

Regardless of whether an MAO offers a coordinated care plan in the area with Part D

benefits, all Special Needs plans (SNPs) are required to include Part D prescription drug

coverage (see the definition of SNPs at 42 CFR §422.2).

Note that Over-the-Counter (OTC) drug benefits are not classified as Part D prescription

drug benefits.

Table II: Part D Prescription Drug Coverage by Plan Type

Plan Type

Regional or

Local MA

Plan?

Must offer Part

Can an enrollee

elect a PDP?

MA Coordinated Care Plan (CCP)

HMO, Point of Service

(HMOPOS), Provider Sponsored

Organization (PSO)

Local

Yes, unless

another non-SNP

MA plan offered

by the same

organization in the

same service area

includes required

prescription drug

coverage under

Part D (42 CFR

422.4(c))

PPO

Either

Yes, unless

another non-SNP

MA plan offered

by the same

organization in the

same service area

includes required

prescription drug

coverage under

Part D (42 CFR

422.4(c)).

Special Needs Plan (SNP)

Either

Yes, required. 42

CFR 422.2

(definition of

SNP)

Private Fee-for-Service (PFFS)

plan

Local

Yes, provided the

PFFS plan does not

offer Part D

coverage.

MA Medical Savings Account

(MSA) Plan

Local

Not permitted

Yes

Section 1876 Cost Plans

Cost plan offering qualified Part D

prescription drug coverage

No, but Part D

coverage may be

offered as an

optional

supplemental

benefit

Yes

Cost plan offering non-qualified

prescription drug coverage

No. The cost plan

cannot offer both

Part D coverage

and non-qualified

prescription drug

coverage.

Yes

Section 1833 HCPP (Health Care

Pre-payment Plan)

Yes

PACE Programs (Program for

the All-inclusive Care of the

Elderly)

Yes

Notes to Table II:

1. See chapter 5 of the Prescription Drug Benefit manual located at

http://www.cms.gov/Medicare/Prescription-Drug-

Coverage/PrescriptionDrugCovContra/PartDManuals.html for the definition of

required drug coverage.

2. Program for the All-Inclusive Care of the Elderly (PACE) organizations offering

PACE Programs, as defined in section 1894 of the Act generally have elected to

provide Part D coverage in order to receive payment for the prescription drug

coverage that they are statutorily required to provide.

10.16 – Medical Necessity

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Every MA plan:

• Must have policies and procedures, that is, coverage rules, practice guidelines,

payment policies, and utilization management, that allow for individual medical

necessity determinations (42 CFR §422.112(a)(6)(ii));

• Must employ a medical director who is responsible for ensuring the clinical accuracy

of all organization determinations and reconsiderations involving medical necessity.

The medical director must be a physician with a current and unrestricted license to

practice medicine in a State, Territory, Commonwealth of the United States (that is,

Puerto Rico), or the District of Columbia (42 CFR §422.562(a)(4));

• If the MAO expects to issue a partially or fully adverse medical necessity (or any

substantively equivalent term used to describe the concept of medical necessity)

decision based on the initial review of the request, the organization determination

must be reviewed by a physician or other appropriate health care professional with

sufficient medical and other expertise, including knowledge of Medicare coverage

criteria, before the MAO issues the organization determination decision. The

physician or other health care professional must have a current and unrestricted

license to practice within the scope of his or her profession in a State, Territory,

Commonwealth of the United States (that is, Puerto Rico), or the District of Columbia

(42 CFR §422.566(d), MMCM chapter 13, 40.1.1);

• Must make determinations based on: (1) the medical necessity of plan-covered

services - including emergency, urgent care and post-stabilization - based on internal

policies (including coverage criteria no more restrictive than original Medicare’s

national and local coverage policies) reviewed and approved by the medical director;

(2) where appropriate, involvement of the organization’s medical director per 42 CFR

§422.562(a)(4); and (3) the enrollee's medical history (e.g., diagnoses, conditions,

functional status), physician recommendations, and clinical notes. Furthermore, if the

plan approved the furnishing of a service through an advance determination of

coverage, it may not deny coverage later on the basis of a lack of medical necessity

(Program Integrity Manual, chapter 6, Section 6.1.3(A)); and

• Must accept and process appeals consistent with the rules set forth at 42 CFR Part

422, Subpart M, and chapter 13 of the MMCM.

20 – Ambulance, Emergency, Urgently Needed and Post-Stabilization

Services

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

20.1 – Ambulance Services

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs are financially responsible for ambulance services, including ambulance services

dispatched through 911 or its local equivalent, when either an emergency situation exists

as defined in section 20.2 below or other means of transportation would endanger the

beneficiary’s health. The enrollee is financially responsible for plan-allowed cost-sharing.

Medicare rules on coverage for ambulance services are set forth at 42 CFR 410.40. For

original Medicare coverage rules for ambulance services, refer to chapter 10 of the

Medicare Benefit Policy Manual, publication 100-02, located at

http://www.cms.hhs.gov/manuals/Downloads/bp102c10.pdf.

20.2 – Definitions of Emergency and Urgently Needed Services

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

An emergency medical condition is a medical condition manifesting itself by acute

symptoms of sufficient severity (including severe pain) such that a prudent layperson,

with an average knowledge of health and medicine, could reasonably expect the absence

of immediate medical attention to result in:

• Serious jeopardy to the health of the individual or, in the case of a pregnant woman,

the health of the woman or her unborn child;

• Serious impairment to bodily functions; or

• Serious dysfunction of any bodily organ or part.

Emergency medical condition status is not affected if a later medical review found no

actual emergency present.

Emergency services are covered inpatient and outpatient services that are:

• Furnished by a provider qualified to furnish emergency services; and

• Needed to evaluate or treat an emergency medical condition.

Urgently needed services are covered services that:

• Are not emergency services as defined in this section but are medically necessary and

immediately required as a result of an unforeseen illness, injury, or condition;

• Are provided when (A) the enrollee is temporarily absent from the plan’s service (or,

if applicable, continuation) area and therefore, he/she cannot obtain the needed

service from a network provider; or (B) when the enrollee is in the service or

continuation area but the network is temporarily unavailable or inaccessible; and

• Given the circumstances, it was not reasonable, for the enrollee to wait to obtain the

needed services from his/her regular plan provider after the enrollee returns to the

service area or the network becomes available.

An MA organization may choose to cover non-emergency services outside the network at

higher cost-sharing.

20.3 – MAO Responsibilities for Coverage of Emergency Services

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

The MAO must inform enrollees of their right to call 911 and:

• No materials furnished to enrollees, including wallet card instructions, may contain

instructions to seek prior authorization for emergency or urgently needed services;

and

• No materials furnished to providers, including contracts, may contain instructions to

providers to seek prior authorization before the enrollee has been stabilized.

The MAO is financially responsible for emergency services and urgently needed

services:

• Regardless of whether services are obtained within or outside the plan’s authorized

service area and/or network (if applicable);

• Regardless of whether there is prior authorization for the services;

• If the emergency situation is in accordance with a prudent layperson’s definition of

“emergency medical condition,” regardless of the final medical diagnosis; and

• Whenever a plan provider - a provider with whom the MAO has a written contract to

furnish plan covered services to its enrollees - or other plan representative instructs an

enrollee to seek emergency services within or outside the plan.

The MAO is not responsible for the care provided for an unrelated non-emergency

problem during treatment for an emergency situation. For example, if the attending

physician is treating a fracture, the plan is not responsible for any costs connected with a

biopsy of skin lesions performed while treating the facture.

20.4 – Stabilization of an Emergency Medical Condition

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The physician treating the enrollee must decide when the enrollee may be considered

stabilized for transfer or discharge, and that decision is binding on the MAO. Refer to

section 20.5 below for the MAO’s obligations regarding services provided following

stabilization. Chapter 13 of the MMCM, “MA Beneficiary Grievances, Organization

Determinations, and Appeals,” addresses the enrollee’s right to request a Quality

Improvement Organization review of hospital discharges to a lower level of care. For

transfers from one inpatient setting to another inpatient setting, an enrollee or person

authorized to act on his or her behalf who disagrees with the decision and believes the

enrollee cannot safely be transferred may request that the organization pay for continued

out-of-network services. If the MAO declines to pay for the services, appeal rights are

available to the enrollee.

20.5 – Post-Stabilization Care Services

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

20.5.1 – Definition of Post-Stabilization

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

Post-stabilization care services are covered services that are:

• Related to an emergency medical condition;

• Provided after an enrollee is stabilized; and

• Provided to maintain the stabilized condition, or under certain circumstances (see

below), to improve or resolve the enrollee’s condition.

20.5.2 – MAO Financial Responsibility

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

The MAO is financially responsible for post-stabilization care services obtained within or

outside the MAO that:

• Are pre-approved by a plan provider or other MAO representative;

• Although not pre-approved by a plan provider or other MAO representative, are

administered to maintain the enrollee’s stabilized condition within one hour of a

request to the MAO for pre-approval of further post-stabilization care; or

• Although not pre-approved by a plan provider or other MAO representative, are

administered to maintain, improve, or resolve the enrollee’s stabilized condition

when:

o The MAO does not respond to a request for pre-approval within one hour;

o The MAO cannot be contacted; or

o The MAO representative and the treating physician cannot reach an agreement

concerning the enrollee’s care, and a plan physician is not available for

consultation.

(In this situation, the MAO must give the treating physician the opportunity to consult

with a plan physician. The treating physician may continue with care of the patient until a

plan physician is reached or one of the criteria below is met.)

20.5.3 – End of Post-Stabilization

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

The MAO’s financial responsibility for post-stabilization care services it has not pre-

approved ends when:

• A plan physician with privileges at the treating hospital assumes responsibility for the

enrollee’s care;

• A plan physician assumes responsibility for the enrollee’s care through transfer;

• An MAO representative and the treating physician reach an agreement concerning the

enrollee’s care; or

• The enrollee is discharged.

20.5.4 – Cost-Sharing

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

Enrollee charges for post-stabilization care services may not be greater than what the

organization would charge the enrollee if s/he had obtained the services through a

contracted provider of the MAO. For purposes of cost-sharing, post-stabilization care

services begin when the patient is stabilized and the emergency ends.

30 – Supplemental Benefits

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

30.1 – Definition of Supplemental Benefit

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

A supplemental benefit is an item or service not covered by original Medicare, that is

primarily health related and for which the MA plan must incur a non-zero direct medical

cost. These criteria are defined below.

(1) A supplemental benefit may not be a Medicare Part A or Part B covered service;

(2) The item or service must be primarily health related; that is, the primary purpose of

the item or service is to prevent, cure or diminish an illness or injury. If the primary

purpose of the item or service is comfort, cosmetic or daily maintenance, then it is not

eligible as a supplemental benefit. The primary purpose of an item or service is

determined by national typical usages of most people using the item or service, or by

community patterns of care; and

(3) The MA plan must incur a non-zero direct medical cost in providing the benefit. If the

MA plan only incurs an administrative cost, this requirement is not met.

An item or service that meets the above three conditions may be proposed as a

supplemental benefit in an MA plan’s bid and submitted plan benefit package. The final

determination of benefit status is made by CMS during the annual benefit package

review.

Mid-year benefit enhancements are not allowed for non-employer plans. For more

information regarding requirements specific to employer group plans, please refer to

chapter 9 of the MMCM, “Employer/Union Sponsored Group Health Plans.”

MA plans are allowed to cover some benefits over more than one contract year. Such

benefits, referred to as “multi-year” benefits, are supplemental benefits that are provided

to an MA plan’s Medicare enrollees over a period exceeding one contract year. For

example, it is permissible for an MA plan to cover one new pair of eyeglasses every two

years. While some benefits may be appropriately offered over multiple years, CMS encourages MA plans to limit offerings to one

contract year where possible.

Supplemental benefits need not be provided through Medicare providers nor at Medicare

certified facilities. Please note, however, MA plans may not make payment to providers

who have opted out or been excluded from Medicare through §§422.220 and

422.204(b)(4)/422.752(a)(8).

30.2 – Supplemental Benefits Extending Original Medicare Benefits

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

In designing supplemental benefits that extend original Medicare benefits, MA plans

should consider:

• Medical Necessity: An MA plan may offer coverage of a supplemental benefit only if

it is medically necessary and additional to the benefit covered by original Medicare.

For example, an MA plan may offer additional inpatient hospital days as a

supplemental benefit. An MA plan may not offer home health coverage or home

health services beyond that covered by original Medicare, if the Home Health Agency

Manual has classified those additional services as not covered by original Medicare

because they are not considered medically necessary. The Home Health Agency

Manual is located in chapter 7 of the Medicare Benefit Policy manual, located at:

http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/bp102c07.pdf, publication 100-02. (All

original Medicare manuals may be found in the Internet-only and paper-based manual

links located at http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.)

• Distinct Naming: An MA plan must be careful in the selection of terminology

describing a supplemental benefit that furnishes coverage beyond that of original

Medicare. The terminology should make clear what the supplemental benefit is. An

MA plan offering a supplemental benefit for which there is no specified service

category in the PBP must use CMS-specified terminology, if available.

• Prohibition of Benefits for Non-enrollees: An MA plan may not offer as a benefit

services furnished to a person other than the enrollee (unless original Medicare

specifically allows such services, e.g., original Medicare coverage of a living donor

for medical complications arising from a kidney transplant). Similarly, other than the

original Medicare respite benefit, an MA plan may not offer other types of caregiver

support as a supplemental benefit. However, an MA plan may, and is even

encouraged, to include information about services available in the community to

assist caregivers in obtaining relief so long as the MA plan does not refer to those

services as plan benefits. Such information may be included in newsletters or other

communications to enrollees, for example. For information on the original Medicare

respite benefit see publication 100-02, the Medicare Benefit Policy Manual, chapter

• Benefit Naming Conventions: An MA plan should not single out specific aspects of

the benefit, in its marketing materials and PBP descriptions of original Medicare

benefits. For example:

o An MA plan may state that it offers “ESRD services;” however, it need not further

mention that “living donor expenses” are covered because “ESRD services”

specifically includes “living donor expenses.” It would be misleading, from a

marketing perspective, to single out only one aspect of the benefit.

o While an MA plan must offer “Occupational Therapy,” it should not single out

any particular aspect of this coverage in its marketing materials, such as massage

therapy, or indicate that it offers “massage therapy” as a benefit. Similarly,

although an MA plan may offer “chiropractic visits” as a benefit, the description

of the benefit should not include the word “massage,” even though the

chiropractor may use massage during the visit.

Examples of benefits meeting these standards that are eligible for MA plans to offer as

supplemental benefits include:

• Additional days or sessions of certain original Medicare covered services such as

inpatient days, sessions of smoking and tobacco cessation counseling, cardiac

rehabilitation, pulmonary rehabilitation.

• Expansion of coverage to allow enrollees to receive benefits for which they do not

qualify under original Medicare such as medical nutrition therapy for enrollees that

do not meet original Medicare coverage criteria and transportation services for non-

emergency purposes.

Table III: Medicare Covered Benefits with Related Supplemental Benefit

Fields in the PBP

Medicare Covered Benefits

Benefits Eligible to be offered as a

Supplemental Benefits

Inpatient Hospital-Acute

Additional Days

Non-Medicare covered stays

Upgrades

Inpatient Hospital-Psych

Additional Days

Non-Medicare covered stays

Skilled Nursing Facility

Additional Days

Emergency Care

Worldwide Emergency/Urgent Coverage

Chiropractor

Routine Care/Other*

Podiatry

Routine Care

Outpatient Blood

Waiver of 3 pint deductible

Medicare Part B Rx & Home

Infusion Drugs

Home Infusion Bundled Services

$0 Cost-sharing Preventive

Services

Additional Smoking and Tobacco Use

Cessation Counseling

Comprehensive Dental

Services

Routine services, diagnostic services,

restorative, endodontic/periodontal/extractive,

prosthodontics, Other oral/maxillofacial

surgery, other services

Eye Exams

Routine eye exams/Other*

Eye Wear

Contact lenses, eye glasses, lenses, frames,

upgrades

Non-routine Hearing Exams

Routine hearing exams, fitting/evaluation for

hearing aids

*“Other” refers to any Non-Medicare covered service

Table III identifies the Medicare-covered and other benefits for which supplemental

benefits are coded into the PBP as options. Other supplemental benefits to extend original

Medicare coverage may be entered in the PBP “Other Supplemental Benefit” fields. CMS

will review these benefits during bid review.

30.3 – Examples of Eligible Supplemental Benefits

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The list below identifies items or services that may be offered as supplemental benefits,

subject to CMS bid review and meeting the criteria identified in section 30.1. Definitions

and limitations of the eligible benefits are provided below. This list below is intended to

be illustrative, not exhaustive.

Acupuncture

The acupuncture provided by MA plans as a supplemental benefit must be provided by

practitioners who are licensed or certified, as applicable, in the state in which they

practice and are furnishing services within the scope of practice defined by their licensing

or certifying state.

Alternative Therapies

MA plans may offer alternative therapies as supplemental benefits. These alternative

therapies must be provided by practitioners who are licensed or certified, as applicable, in

the state in which they practice and are furnishing services within the scope of practice

defined by their licensing or certifying state. MA plans are to provide a description of

therapies offered in the PBP Notes section.

Bathroom Safety Devices

MA plans may choose to offer, as a supplemental benefit, provision of specific non-

Medicare-covered safety devices to prevent injuries in the bathroom. In addition to

providing and installing appropriate safety devices, the benefit may include an in-home

bathroom safety inspection conducted by a qualified health professional, in accordance

with applicable state and Federal requirements, to identify the need for safety devices, as

well as the applicability to the specific enrollee’s bathroom (e.g., to determine whether a

specific safety device can be installed into the bathroom).

The MA plan should describe the proposed benefit and, if an in-home assessment is

offered, the qualifications of the health professional that will be performing those

evaluations, in its submitted PBP.

Routine Chiropractic Services

MA plans may choose to offer routine chiropractic services as a supplemental benefit as

long as the services are provided by a state-licensed chiropractor practicing in the state in

which he/she is licensed and is furnishing services within the scope of practice defined by

that state’s licensure and practice guidelines. The routine services may include

conservative management of neuromusculoskeletal disorders and related functional

clinical conditions including, but not limited to, back pain, neck pain and headaches, and

the provision of spinal and other therapeutic manipulation/adjustments.

X-rays or other diagnostic or therapeutic services furnished or ordered by a chiropractor

may be covered by the MA plan as a supplemental benefit as long as the chiropractor is

state-licensed and is practicing within the states’ licensure and practice guidelines.

Counseling Services

Medicare Part B covers individual and group therapy services to diagnose and treat

mental illness. The Part B coverage usually requires a physician referral for mental health

care and is based on a mental health diagnosis.

Counseling services not covered by original Medicare may be offered as a supplemental

benefit to all beneficiaries. These supplemental benefits may address general topics, such

as: coping with life changes; conflict resolution; or grief counseling and be offered as

individual or group sessions.

Fitness Benefit

Fitness benefits (e.g., fitness center membership, exercise and yoga classes) may be

offered by MA plans as supplemental benefits designed to improve or maintain good

health. The fitness benefit must, if applicable, include an orientation for each enrollee to

the facility and the equipment. The benefit also may include development of a

personalized exercise plan and a limited number of sessions with a certified trainer.

MA plans may not offer personal trainers or exercise coaches for in-home sessions.

MA plans should describe specifically what is included in the supplemental fitness benefit

(e.g., access to fitness center or other facilities, support staff, general goals of the

program) in the applicable PBP notes field.

Enhanced Disease Management (EDM)

Non-SNP MA plans may offer Enhanced Disease Management (EDM) as a supplemental

benefit. EDM must be targeted to groups of enrollees based on a diagnosis of, or risk for,

a specific disease condition (e.g., diabetes, heart failure, cognitive impairment such as

Alzheimer’s and related dementias). Services that CMS would expect to be included in a

supplemental “EDM” benefit for coordinated care plans, and which would be expected to

be approved as supplemental benefits, would include the following three activities:

• Enrollees in the target group are assigned to qualified case managers with

specialized knowledge about the disease(s) who contact the enrollee to provide

additional case management and monitoring services. We believe that this should

be an essential aspect of an effective EDM program and it is important for MA plans

to understand the difference between the assignment of case managers for all

enrollees and the assignment of a case manager with specialized knowledge about a

specific individual enrollee’s disease(s). The case manager or other qualified health

professional assigned to the enrollee should work to ensure that the enrollee makes

and keeps appointments necessary to receive appropriate care from physicians and

other health care providers including obtaining preventive services. That assigned

case manager or other qualified health professional should facilitate the enrollee’s

participation in both standard disease management activities and supplemental EDM

programs offered by the MA plan. The assigned case manager or other qualified

health professional should ensure that all scheduled monitoring of the enrollee takes

place and that information is analyzed and communicated to all members of the care

team so that early signs of deterioration in the enrollee’s condition are detected and

action is taken to prevent further deterioration.

• Educational activities being provided by certified or licensed professionals that

are focused on the specific disease/condition. Educational programs are designed to

help enrollees develop knowledge and self-care skills and to foster the motivation and

confidence necessary to use those skills to improve health. Examples of educational

services that may qualify as a supplemental benefit include provision of information

about the specific disease process(es), treatments and drug therapies, signs and

symptoms to watch for, self-care strategies and techniques, dietary restrictions, and

nutritional counseling.

• Routine monitoring of measures, signs and symptoms, applicable to the specific

disease(s)/condition(s) of the enrollee. We expect the MA plan to collect and act

upon the information gathered from routing monitoring in order to coordinate care in

an appropriate and timely manner. Clinical staff with specialized knowledge of the

enrollee’s specific disease/condition should conduct this review of the EDM program.

Health Education

A health education program may be offered as a supplemental benefit if it:

• Is offered to all enrollees or targeted to groups of enrollees based on a diagnosis of, or

risk for, a specific disease condition (e.g., diabetes, heart failure, cognitive

impairment such as Alzheimer’s and related dementias);

• Provides more than written material or a website and go beyond content alone to

include interaction with a certified health educator or other qualified health

professional.

The interactive sessions are expected to:

• Primarily provide health information;

• Encourage enrollees’ adoption of healthy behaviors;

• Build skills to enhance enrollees’ self-care capabilities;

• Align with the overall goal to improve participants’ health; and

• May be provided in a number of modalities including, but not limited to:

o Group sessions in which the educator provides information or skills

instruction;

o One-on-one instructional sessions; and

o Interactive web- and/or telephone-based coaching to reinforce what an

enrollee learned in a group or individual session.

Consistent with our description of health education activities and services above, MA

plans may develop health education services to address health-related topics they identify

as appropriate for their enrollee population and could include, as supplemental benefits,

programs that support and encourage enrollees to adopt healthier lifestyles.

In-Home Safety Assessment

The In-Home Safety Assessment should be performed by an occupational therapist or

other qualified health provider. Services included in such a benefit are provided only to

enrollees who do not qualify for an in-home safety assessment under original Medicare’s

home health benefit and the MA plan must ensure the following conditions apply:

• The assessment’s focus is on the beneficiary’s risk for falls or injuries and

identification of how falls may be prevented; and

• The bathroom safety devices that may be installed should be appropriate for the

individual beneficiary’s home, determined to be necessary by the occupational

therapist or other qualified health provider furnishing the safety assessment in order

to prevent injury, and be approved by the beneficiary.

The assessment may include identification and/or minor modification of some home

hazards outside of the bathroom, in order to reduce risk of injury. Such modifications

may include removal of rugs that are not attached to the floor and rearrangement of

furniture to create clear pathways.

Meals

Meals may be offered as a supplemental benefit to address the following two types of

circumstances:

• Immediately following surgery or an inpatient hospital stay, for a temporary duration,

typically a four-week period, per enrollee per year, provided they are ordered by a

physician or non-physician practitioner. As discussed in 42 CFR § 422.112(b)(3),

after the temporary duration, the provider should refer the enrollee to community and

social services for further meals, if needed, or

• For a chronic condition, including but not limited to cardiovascular disorders, COPD

or diabetes, for a temporary period, typically two weeks, per enrollee per year

provided they are ordered by a physician or non-physician practitioner; and are part

of a supervised program designed to transition the enrollee to life style modifications.

Home delivery of meals may be offered as a supplemental benefit if the services are:

1) Needed due to an illness;

2) Consistent with established medical treatment of the illness; and

3) Offered for a short duration.

Social factors, by themselves, do not qualify an enrollee for meal services.

Note that all MA coordinated care plans are required to “coordinate MA benefits with

community and social services generally available in the area served by the MA plan”

(§422.112(b)(3)). Therefore, MA plans are to:

• Provide information and links to websites with nutritious diet planning information,

such as ChooseMyPlate.Gov;

• Provide nutritional tips in their newsletters and/or on their websites; and

• Partner with social community services such as “Meals on Wheels.”

However, the MA plan may not classify any of these community services as plan

benefits. Additionally, an MA plan offering a meal benefit complying with the

requirements described in this chapter may not advertise it as a “Meals on Wheels”

benefit or use the term “Meals on Wheels” in the name of the benefit. It is important that

prospective enrollees not confuse the limited meal services offered as a supplemental

benefit with the broader services offered under the “Meals on Wheels” program.

However, if an MA plan has entered into a contract with “Meals on Wheels” to furnish

the approved meals benefit, it may inform its enrollees that the supplemental benefit

(meal benefit) under the MA plan will be delivered by “Meals on Wheels.”

Nutritional/Dietary Benefit

General nutritional education for all enrollees through classes and/or individual

counseling may be provided as a supplemental benefit as long as the services are

provided by practitioners who are practicing in the state in which s/he is licensed or

certified, and are furnishing services within the scope of practice defined by their

licensing or certifying state. (i.e., physician, nurse, registered dietician or nutritionist).

The number of visits, time limitations, and whether the benefit is for classes and/or

individual counseling must be defined in the PBP.

Over-the-Counter (OTC) Benefit

MA plans may offer OTC items as a supplemental benefit under Part C. OTC items

include non-prescription drugs, also known as OTC drugs and health-related items. See

section 40 below for details.

Personal Emergency Response System (PERS)

MA plans may provide enrollees with in-home Personal Emergency Response devices

designed to notify appropriate personnel of an emergency (e.g., a fall), provided that they

are primarily health related. A PERS may not include cellular telephones because such

devices are not primarily health related (a definitive component of being a supplemental

benefit).

Preventive Benefits Eligible as Supplemental Benefits

An example of a preventive benefit that is eligible as a supplemental benefit is providing

additional sessions of smoking and tobacco cessation counseling. MA plans may offer

additional sessions of face-to-face intermediate counseling and/or additional sessions of

face-to-face intensive counseling per contract year and/or the MA plans may offer as a

supplemental benefit interactive, on-line or telephone-based coaching and support

programs to enhance enrollees’ successful smoking and tobacco cessation.

Medical Nutrition Therapy (MNT)

MA plans may offer as a supplemental benefit additional hours of one-on-one MNT

counseling provided by a registered dietician or other nutrition professional, to enrollees

who are eligible for the Medicare Part B-covered MNT benefit; that is, those with

diabetes, renal disease, or who have received a kidney transplant in the last three years. In

addition, MA plans may offer as a supplemental benefit one-on-one MNT counseling

provided by a registered dietician or other nutrition professional, to all, or a disease-

defined group, of its enrollees. As with all supplemental benefits, the MNT benefit’s

primary purpose must be to improve health outcomes.

Physical Exam

Non-SNP MA plans may offer as a supplemental benefit a physical exam that provides

services beyond those services required to be provided in the Annual Wellness Visit. To

be considered an Annual Physical Exam that qualifies as a supplemental benefit by CMS,

the exam would be provided by a qualified physician or qualified non-physician

practitioner, hereafter referred to as a practitioner. At a minimum, the exam would

include a detailed medical/family history and the performance of a detailed head to toe

assessment with hands-on examination of all the body systems. For example, the

practitioner uses visual inspection, palpation, auscultation and 133 manual examination

in his/her full examination to assess overall general health and detect abnormalities or

signs that could indicate a disease process that should be addressed. We consider these

components minimum elements and not an exhaustive list.

Other aspects of the Annual Physical Exam may include, as appropriate, follow-up

orders for referral to other practitioners, lab tests, clinical screenings, EKG, etc. The

Annual Physical Exam also should emphasize prevention, i.e., the recommendations for

preventive screenings, vaccination(s), and counseling about healthy behaviors.

Practitioners should exercise clinical judgment when determining the additional

components necessary for an Annual Physical Exam to meet the individual needs of the

enrollee. MA plans do not need to fully describe in the PBP notes the non-Medicare

covered activities and services included in the physical exam if the benefit is consistent

with our guidance.

Point of Service (POS)

HMOs may offer a POS option as a mandatory or optional supplemental benefit pursuant

to 42 CFR 422.105 and 422.111. This supplemental benefit may not be offered by any

other MA plan type. The POS benefit provides coverage for some plan-covered services

outside of the HMO’s network. The HMO plan:

• May limit POS benefits to certain items and services, geographic area, or provider(s);

• May require that enrollees pay higher cost-sharing (e.g., deductibles) for POS

services;

• May either require or waive prior authorization rules for obtaining POS services;

• May establish a plan maximum dollar amount it will pay for the POS benefit and/or a

enrollee maximum out-of-pocket maximum for the POS benefit; if the plan chooses

to establish a plan maximum dollar amount, it must inform the enrollee how much

cost-sharing is required before the enrollee reaches this maximum amount and

explain that the enrollee is liable for 100% of the cost of services after the enrollee

has reached the plan maximum;

• Must fully disclose and clearly specify all limitations (e.g., benefits, geographic area,

providers) and describe all POS benefits and cost-sharing;

• Must track enrollee and plan utilization and spending for POS services and provide

this information to enrollees (i.e., in advance of meeting limitations and/or upon

request by the enrollee); and

• Must be prepared to report enrollee utilization of contracting and non-contracting

providers, at the plan level and in the form and manner prescribed by CMS.

Note: A PPO must cover all plan benefits furnished to its enrollees anywhere in the

United States. Therefore, an MAO wishing to furnish specific plan-covered services

outside its service area, but only in certain geographic locations, should offer an HMO

plan with a POS option.

Post-discharge In-home Medication Reconciliation

An MA plan may offer a post-discharge medication reconciliation as a supplemental

benefit. For example, immediately following discharge (e.g., within the first week) from

a hospital or SNF inpatient stay, MA plans may offer, as a supplemental benefit, the

services of a qualified health care provider who, in cooperation with the enrollee’s

physician, would review the enrollee’s complete medication regimen that was in place

prior to admission and compare and reconcile with the regimen prescribed for the

enrollee at discharge to ensure new prescriptions are obtained and discontinued

medications are discarded. This reconciliation of the enrollee’s medications may be

provided in the home and is designed to identify and eliminate medication side effects

and interactions that could result in illness or injury.

Readmission Prevention

MA Plans may offer, as a supplemental benefit, non-Medicare covered services that are

primarily for the purpose of preventing the enrollee’s readmission to a hospital or other

institution, immediately following an enrollee’s discharge from a hospital or skilled

nursing facility (SNF) inpatient stay (e.g., within the first week).

Services included in a supplemental readmission prevention benefit that CMS would

expect to approve would:

• Not duplicate Medicare-covered benefits (e.g., home health which may provide some

services to homebound beneficiaries);

• Be initiated immediately after an enrollee’s discharge from an institutional setting

(e.g., hospital, SNF); and

• Be provided for a limited and specified period of time not to exceed four weeks.

An MA plan may combine the benefits, suggested as examples below, as a complete

“Readmission Prevention” benefit or offer the benefits separately. Examples include:

• In-Home Safety Assessment as described earlier in this section;

• Meals, as described earlier in this section; and

• Post discharge In-home Medication Reconciliation, as described earlier in this

section;

Remote Access Technologies (including Web/Phone based technologies and Nursing

Hotline)

MA plans may propose a supplemental benefit to allow a contracted provider to diagnose

and treat some conditions via telephone, and/or real time interactive audio and video

technologies. MA plans must ensure that this type of service will not be used as a

substitute for an effective, ongoing doctor-patient relationship, but rather, will be

supportive of that relationship and of efficient delivery of needed care. MA plans offering

such a benefit should ensure that:

• Enrollees are not required to use remote access technologies, but may choose to use

those services;

• Medical protocols are established and regularly updated based on relevant clinical

guidelines and that prescribing and/or treatment recommendations are consistent with

the state laws in the jurisdiction where the MA plan operates and are within the

provider’s scope of practice;

• The enrollee is made aware when using the technology that he or she is not required

to use it and may contact his/her plan provider directly and request an in-person

appointment;

• The information provided by, and to, the enrollee during the interactive process is

directed to his/her PCP or other plan provider specified by the enrollee and will

become part of the enrollee’s medical record; and

• The MA plan will have a protocol for monitoring the use of the system by enrollees.

The protocol should enable the MA plan to identify potential misuse and instances

where the system is supplanting appropriate PCP visits. The protocol should be

implemented at the beginning of the contract year the benefit is offered. The MA plan

must provide CMS with this information upon request.

A PPO may not use remote access technologies services as described above to fulfill its

requirement to provide out-of-network services. Email communication between an

enrollee and his/her physician would not be acceptable as a supplemental benefit because

that communication is part of the Part B physician services MA plans are required to

provide.

MA plans must include in the 110.1 field a description of the remote access technologies

services they propose to provide as a mandatory supplemental benefit. In addition, the

remote access technology supplemental benefit may not replace the Medicare telehealth

basic benefit described at 42 CFR § 414.65.

Repairs

Repairs of an item furnished as a supplemental benefit may be included as part of that

supplemental benefit, as appropriate (e.g., eye glass and hearing aid repairs). However, as

indicated in section 10.12, repairs of Medicare-covered DME are part of the Part B

benefit and, consequently, may not be offered as supplemental benefits.

Telemonitoring Services

MA plans may offer a supplemental benefit that provides in-home equipment and

telecommunication technology to monitor enrollees with specific health conditions (e.g.,

hypertension or heart failure). The benefit should be referred to as “Telemonitoring

services” in the PBP and may not duplicate items or services provided under original

Medicare (e.g., glucometers for diabetic beneficiaries). MA plans should include in the

PBP notes field a description of the monitoring services they propose to provide as

supplemental benefits. These benefits are distinct from telehealth benefits covered under

original Medicare (see 42 CFR § 414.65). Telemonitoring equipment may not include a

cellular telephone because such devices are not primarily health related. In addition, the

supplemental benefit description should address the following issues:

• Telemonitoring services supplement, rather than replace, face-to-face physician visits;

• The enrollee should have an initial physician visit to diagnose or confirm the

diagnosis of the specific condition prior to the use of the telemonitoring benefit;

• Except in rare circumstances, the data submitted should be collected/transmitted at

least weekly, but may be sent daily or more frequently, as appropriate for the

particular disease;

• The equipment provided to the enrollee should be disease-appropriate;

• The enrollee should be trained on how to use the equipment and transmit the data

properly;

• Health care professionals should monitor and take action, as needed, based on the

collected/transmitted data;

• The enrollee’s physician should be included in the communication process; and

• All devices must comply with applicable state and federal requirements.

Transportation Services

An MA plan is not obligated to provide transportation to obtain non-emergent, covered

Part A and Part B services. However, such transportation may be offered as a

supplemental benefit.

The transportation offered must be used exclusively to accommodate the enrollee’s health

care needs: for example, the MA plan may offer a supplemental benefit that provides

transportation to enrollees for physician office visits. The transportation must be

arranged, or directly provided, by the MA plan and may not be used to transport enrollees

for non-health-related purposes. The MA plan must describe the proposed benefit in the

PBP.

Visitor/Travel Benefit

A Visitor/Travel (V/T) benefit may be offered as a supplemental benefit as a means to

provide covered services outside of the service area of the MA plan. Under plan

enrollment rules, MA plans that do not offer a V/T supplemental benefit must disenroll

current enrollees who are temporarily absent from the MA plan’s service area for more

than six consecutive months. However, MA plans that offer a V/T benefit may retain

enrollees who are covered by the benefit, but temporarily out of the service area (and still

within the United States or its territories) for more than six, but less than 12 months (42

CFR § 422.74(d)(4)(iii)). See chapter 2 of the MMCM, “Medicare Advantage Enrollment

and Disenrollment,” located at

http://www.cms.gov/MedicareMangCareEligEnrol/01_Overview.asp, for further details.

The specific requirements for the V/T benefit are as follows:

• The V/T benefit must furnish all plan-covered services in its designated V/T

service area(s), including all Medicare Part A and Part B services and all

mandatory and optional supplemental benefits, at in-network cost-sharing levels,

consistent with Medicare access and availability requirements at 42 CFR

§422.112;

• The MA plan must define the geographic areas within the United States and its

territories where the V/T benefit is available;

• The V/T benefit must be available to all plan enrollees covered by the benefit who

are temporarily in the designated geographic areas where the V/T benefit is

offered;

• V/T benefits may not be offered outside the United States and its territories; and

• Subject to compliance with Medicare access requirements and CMS review of

bids, an MA plan may designate an area where it is not able to form a network of

direct-contracted providers as a covered V/T service area as long as the plan can

ensure that its enrollees have access to all covered services.

Weight Management Programs

Weight management programs may be offered as a supplemental benefit designed to

promote healthy behaviors that help an individual to lose weight and keep it off, but the

program may not offer meals as part of the benefit. As with all supplemental benefits,

Weight Management Programs must be health driven and aim to improve health

outcomes. For CMS to consider a Weight Management Program sufficiently health

related, the benefit includes:

• A plan to keep the weight off over the long run:

• Guidance on how to develop healthier eating and physical activity habits; and

• Ongoing feedback, monitoring, and support.

The weight management program should provide structured lessons on a weekly basis

that are tailored to the beneficiaries’ personal goals. The program should support self-

monitoring of eating and physical activity as well as offer regular feedback from a

counselor on goals, progress, and results. The program may be offered online (fully or

partly), but must also be entirely available to enrollees without access to online

capabilities.

Wigs for Hair Loss Related to Chemotherapy

An MA plan may offer as a supplemental benefit wigs for hair loss that is a result of

chemotherapy. However, wigs may not be offered as a supplemental benefit for any other

purpose.

Worldwide Emergency/Urgent Coverage

Worldwide Emergency/Urgent Coverage refers to coverage of services, either as a

mandatory or optional supplemental benefit, outside the United States and its territories.

Under this benefit, enrollees may obtain only services that would be classified as

emergency and urgently needed services had they been covered inside the United States.

MA plans that offer a Worldwide Emergency/Urgent Coverage benefit may retain

enrollees who are covered by the benefit but temporarily outside of the United States or

its territories for up to six months. This coverage may also include ambulance services

worldwide.

As explained in section 10.5.2 above, a plan benefit design may not discriminate based

on health status. In particular, the cost of a mandatory supplemental Worldwide

Emergency/Urgent Coverage benefit should be nominal within the bid; otherwise, CMS

may determine that the benefit discriminates against enrollees who are unable to travel

due to health status.

30.4 – Items and Services Not Eligible as Supplemental Benefits

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The items and services listed in this section have been previously proposed by MA plans

as supplemental benefits in submitted plan benefit packages and, because they are not

sufficiently health related, are not allowable supplemental benefits:

• Cosmetic services, including, but not limited to beauty salon services such as

pedicures and manicures;

• Homemaker and maid services (when not covered by the original Medicare Home

Health benefit);

• A massage benefit even when furnished by a state licensed massage therapist;

• Stand-alone peripherals such as hearing aid batteries and contact lens cases when not

factory packaged with the hearing aids or contact lenses, respectively;

• Meals not meeting the criteria specified in section 30.3 above;

• Smoke detectors and fire extinguishers;

• Screening Pap test/screening pelvic exams provided more frequently than every 24

months for non-high risk enrollees. This policy follows the Medicare Part B schedule;

• Electronic medical records and electronic data storage devices;

• Loaner DME items when the enrollee’s rented or owned DME is being repaired.

Loaner DME is a required Medicare Part B service. See section 10.12 above;

• A stand-alone memory fitness benefit (Note: Memory fitness activities may be

offered as a component of a health education supplemental benefit); and

• Case management and care coordination services because these are required activities

in all coordinated care plans. Those required activities are described in section 110.5

of this chapter.

Note: For information specific to Special Needs Plan benefit offerings, see chapter 16b of

the MMCM, “Special Needs Plans.”

40 – Over-the-Counter (OTC) Benefits

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

40.1 – Overview of OTC Benefit

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MA plans may offer as a supplemental benefit health-related items and medications that

are: available without a prescription, and are not covered by Medicare Part A, Part B or

Part D. MA plans may never offer as a Part C supplemental benefit an OTC drug or item

that also is covered under Part B or that is paid for under Part D for the plan’s enrollees.

OTC drugs and items that are eligible to be included in a Part C supplemental benefit

must meet our criteria for qualification as a supplemental benefit in section 30 of this

chapter. Detailed information about OTC drugs paid for under Part D may be found in

Chapters 5 and 7 of the Medicare Prescription Benefit Manual, Pub 100-18.

Under Part C, MA plans may cover health-related OTC items such as adhesive or elastic

bandages, and OTC drugs such as antihistamines and analgesics, that meet the criteria as

eligible supplemental benefits under Part C, presented in section 30.1 above.

Medical supplies associated with the administration of insulin, (e.g., alcohol wipes and

syringes) must be paid for under Part D and are not eligible to be covered as a

supplemental benefit.

Since items and drugs that may be covered by the MA plan as supplemental benefits are

for the enrollee, OTC items may be purchased for the enrollee only.

40.2 - Access to OTC Benefits

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The OTC drugs and/or items offered, regardless of how they are packaged or paid for,

must be available at a wide variety of retail outlets or through a mail order catalog. The

MA plan must ensure that the retail outlets through which enrollees may obtain the

covered OTC items are distributed within the service area to ensure that the benefit is

uniformly offered and that all enrollees have access to the benefit. An MA plan that

contracts with a single mail order company to provide OTC items has fulfilled its

obligation of providing uniform and sufficient access to the OTC benefit.

An MA plan’s catalog for OTC may consist of an actual paper catalog that displays

covered OTC drugs and/or items, a list on a website, or a simple order form. Enrollees

may place their orders either through a secure website, mail, or a toll-free number. The

OTC catalog must contain: a list of all plan-covered OTC items and the price of each

item. The MA plan is responsible for the cost of mailing. To avoid excessive mailing

costs, the MA plan may impose a minimum purchase amount per order.

40.3 – Payment Methods

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The MA plan may not give enrollees money to purchase covered OTC items or drugs but

may, for example: (1) reimburse enrollees for eligible purchases when receipts are

presented; (2) allow enrollees to purchase OTC items through a plan catalog or list; or (3)

issue a debit card that is electronically linked to eligible OTC items and drugs. The plan

may establish a certain dollar amount that each covered enrollee may spend to purchase

covered OTC items and drugs on a per-month or per-year basis. The method (debit card,

mail order etc.) by which enrollees are able to purchase covered OTC items and drugs is

not part of the benefit and may be changed during the year with appropriate prior

notification to enrollees and the MA plan’s account manager to ensure the new method

provides adequate access.

40.3.1 – Special Rules for Manual Reimbursement

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Every MA plan, independent of the payment method it chooses, must also allow – under

circumstances which it describes (for example, when the debit card network is not

operating correctly) – for manual reimbursement for the purchase of OTC items based on

submitted receipts. The MA plan must indicate the forms and process (as well as the

circumstances) by which manual reimbursement is allowed.

40.4 – Items and Their OTC Status

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Table IV below displays examples of categories of OTC items that MA plans may cover

as supplemental benefits, and also provides guidance to help plans distinguish between

items that would be eligible for coverage and those that would not. Those items shown as

“eligible” OTC items may be purchased by the enrollee without restriction. Those items

shown as “dual purpose” may be purchased only after the enrollee discusses the purchase

with their personal provider (or satisfies other requirements the plan may specify, to

ensure that the covered item or service is health-related and appropriate for the enrollee).

The plan may require a written note from, or a verbal discussion with, the enrollee’s

personal health care provider as a condition for purchase of eligible or dual purpose

items.

Table V displays examples of categories of items that are not eligible as OTC

supplemental benefits because they are not “health benefits” within the meaning of the

statute.

Note: Tables IV and V display categories of items rather than listing individual items. For

example, a plan that chooses to offer cough medicines as a Part C OTC supplemental

benefit must cover all items and brands and may not choose to cover only specified items

or brands, in order to meet access requirements for the benefit.

The plan must clearly indicate in its OTC listing the items and drugs that, under certain

circumstances, may be covered under either Part B or Part D. When an item is covered

by Part B or Part D due to particular circumstances, the enrollee would not use his or her

OTC benefit to obtain the item because it is Medicare-covered in those circumstances,

and not part of the supplemental OTC benefit. For example, gauze may be covered under

Part B when it is being used as prescribed, to perform surgical wound dressing changes.

Table IV: Eligibility Status of OTC Items

Eligible?

Category

Examples of Items/Drugs Included in

this Category

Non-eligible

Alternative

medicines

Homeopathic and alternative medicines

including botanicals, herbals, probiotics

and nutraceuticals

Non-eligible

Baby items

Diapers, formula

Non-eligible

Contraceptives

Birth control pills, spermacide,

prophylactics

Non-eligible

Convenience

and comfort

Scales, fans, magnifying glasses, ear

plugs, insoles, arch supports and gloves

Non-eligible

Cosmetics

Mouthwashes, bad breath remedies,

deodorants, lip soothers, grooming

devices, skin moisturizers, teeth-

whiteners

Non-eligible

Food product

supplements

Sugar / salt supplements, energy bars,

liquid energizers, protein bars, power

drinks

Non-eligible

Replacement

items,

attachments,

peripherals

Hearing aid batteries, contact-lens

containers, etc. when not factory

packaged with the original item

both in- and out-of-network cost-sharing for all Part A and Part B services. The MOOP

dollar limits are set annually by CMS and include all cost-sharing (i.e., deductibles,

coinsurance, and co-payments) for Part A and Part B services, although an MA plan may

also include supplemental benefits as services subject to the MOOP. CMS also may

annually establish a lower, voluntary MOOP limit. Plans that adopt the lower voluntary

MOOP limit will have more flexibility in establishing cost-sharing amounts for Part A

and Part B services than those that do not elect the voluntary MOOP. MAOs must track

enrollee out-of-pocket costs and should notify enrollees when they reach, or are near, the

plan’s MOOP limit.

For any dual eligible enrollee, MA plans must count toward the MOOP limit only those

amounts the individual enrollee is responsible for paying, net of any state responsibility

or exemption from cost-sharing, and not the cost-sharing amounts for services the plan

has established in its plan benefit package. Effectively, this means that, for dual eligible

enrollees who are not responsible for paying the Medicare Part A and Part B cost-sharing,

the MOOP limit will rarely, if ever, be reached. However, plans must still track out-of-

pocket spending for these enrollees.

During a contract year, when an enrollee switches to another plan of the same type (for

example, from one HMO to another HMO) offered by the plan, his/her accumulated

annual contribution toward the annual MOOP limit in the previous plan to date is to be

counted towards his/her MOOP limit in the new MA plan. As applicable, this transfer of

MOOP applies to both in-network and out-of-network MOOP.

Additionally, MA plans may extend the transferability of the enrollee’s contribution

toward his/her annual MOOP so that it applies to an enrollee’s transfer during the

contract year to any MA plan type offered by the MAO. For example, if an enrollee

makes a mid-year change to move from an HMO to a PPO offered by the same MAO,

his/her current contribution toward the MOOP limit may follow the enrollee and be

counted towards the MOOP limit in the PPO. This allows those enrollees who are eligible

to make mid-year plan changes to freely select among the diverse MA plan options

offered by an MAO.

Per Member Per Month (PMPM) Actuarial Equivalent (AE) Cost-sharing Requirement:

The actuarially estimated total MA cost-sharing for Part A and Part B services must not

exceed cost-sharing for those services in original Medicare. In addition, CMS evaluates

particular service categories; inpatient facility, SNF, DME, and Part B drugs, for actuarial

equivalence. MA plans should refer to annually published guidance regarding the

application of this requirement.

Service Category Cost-sharing Standards: As provided under 42 CFR §422.100(f)(6),

MA plan cost-sharing for Part A and Part B services specified by CMS must not exceed

levels annually determined by CMS to be discriminatory. In addition, under section

1852(a)(1)(B)(iii) of the Act (as amended by the Affordable Care Act) the cost-sharing

charged by MA plans for chemotherapy administration services, dialysis services, and

skilled nursing services for which cost-sharing would apply under original Medicare may

not exceed the cost-sharing for those services under Part A and Part B.

Discriminatory Pattern Analysis: CMS may perform an additional general discriminatory

pattern analysis of cost-sharing to ensure that discriminatory benefit designs are

identified and corrected.

Additional cost-sharing guidance:

• MAOs may, in certain situations, use co-payments for services that have CMS cost-

sharing standards based on original Medicare coinsurance levels. In those situations,

the plan may charge a co-payment that is actuarially equivalent, based on the

expected distribution of costs, to the coinsurance standard;

• Plans may not use different co-payment amounts that are based on the cumulative

number of visits (e.g., cost-sharing of $5 for visits 1 through 5, and $10 for visits 6

and greater);

• Any foundation or organization that is owned and operated by an MA plan cannot

pay cost-sharing for MA plan enrollees;

• Deductibles: While high deductibles are required for MSA plans, CMS will closely

scrutinize high deductibles in other plan types;

• Use of Coinsurance vs. Co-payments: CMS will, in its annual review of plan cost-

sharing, monitor both co-payment amounts and coinsurance percentages. Although

MAOs have the flexibility to establish cost-sharing amounts as co-payments or

coinsurance, MAOs should keep in mind, when designing their cost-sharing, that

enrollees generally find co-payment amounts more predictable and less confusing

than coinsurance;

• The 50% cap on original Medicare services: In order for an original Medicare in-

network or out-of-network item or service category to be considered a plan benefit,

plans may not pay less than 50% of the contracted (or Medicare allowable) rate and

cost-sharing for services cannot exceed 50% of the total MA plan financial liability

for the benefit. Consequently:

o If a plan uses a coinsurance method of cost-sharing, then the coinsurance for

an in-network or out-of-network service category cannot exceed 50%;

o If a plan uses a copay method of cost-sharing, then the copay for an out-of-

network original Medicare service category cannot exceed 50% of the average

Medicare rate in that area;

o If a plan uses a copay method of cost-sharing, then the copay for an in-

network original Medicare service category cannot exceed 50% of the average

contracted rate of that service. For example, if the plan’s service area consists

of two counties with equal frequency of utilization with contracted rates for a

particular service of $90 and $110 in the two counties, then the plan may

uniformly charge no more than a $50 copay for that service category; and

o The 50% cap is in addition to any other caps. Thus, for those service

categories subject to fee-for-service cost-sharing limits (e.g. 20% coinsurance)

the plan may not charge more than the fee-for-service cost-sharing limit;

• Stratified co-payments for DME and/or Part B Drugs: MA plans may use a stratified

co-payment arrangement for DME and/or Part B drugs provided that the copayment is

non-discriminatory and follows all Medicare rules. Below is one example of stratified

copayment which would be acceptable to CMS because it is not discriminatory and

does not violate other Medicare rules. In the table below note that: (1) for each strata,

the co-payment amount is no greater than the CMS coinsurance requirement for the

lower limit of the strata, and (2) the number of co-payment strata does not exceed

four. The following example complies with CMS standards.

Cost Range For service Co-payment

$0 - $199 $0

$200 - $499 $40

$500 - $999 $100

$1000 and above $200

• Tiered cost-sharing of medical benefits: The following guidance applies to benefit

package designs that include tiered cost-sharing of medical benefits. MA plans may

choose to tier the cost-sharing for contracted providers as an incentive to encourage

enrollees to seek care from providers the plan identifies based on efficiency and

quality data. The tiered cost-sharing must satisfy the following standards:

o The plan fully discloses tiered cost-sharing amounts and requirements to enrollees

and plan providers;

o The services at each tier of cost-sharing are available to all enrollees;

o Enrollees may not be limited to obtaining services from providers/suppliers

assigned to a particular tier; and

o All enrollees are charged the same amount for the same service provided by the

same provider.

Thus, an MA plan may offer access to two or more physician groups to which

different levels of cost-sharing apply, but it may not require that an enrollee receive

all needed care during the contract year from a particular provider group. Restricting

enrollee choice by requiring that all services be furnished by a specific group within

the network has the effect of creating multiple MA plans within one MA plan and,

therefore, conflicts with the uniformity of premium and cost-sharing requirement (see

42 CFR §422.100(d)(2)).

The following scenarios are examples of ‘differential cost-sharing’ rather than tiering

of medical benefits and are allowed when the variation in cost-sharing is based on:

o Facility settings for furnishing some services, such as diagnostic imaging

services; and

o In-network versus out-of-network services, as explained in sections 110.2, 110.3

and 110.6 below, and in the POS subsection of section 30.3 above.

However, while MA plans may have ‘differential cost-sharing’ based on facility

settings, they should include the enrollee’s entire cost sharing responsibility in a

single copay. This is consistent with Medicare Advantage disclosure requirements at

42 CFR §422.111(b)(2) which require that MA plans clearly and accurately disclose

benefits and cost sharing. Accordingly, in situations where there is a difference in

cost sharing based on place of service, those fees should be combined (bundled) into

the cost sharing amount for that particular place of service and clearly reflected as a

total copayment in appropriate materials distributed to beneficiaries.

• Dialysis Services: Cost-sharing for dialysis services may not exceed the cost-sharing

imposed in original Medicare. The cost-sharing for out-of-network (OON) and out of

service area, medically-necessary dialysis services may not exceed the in-network

cost-sharing. The cost-sharing charged by MA plans for dialysis services furnished in

the service area, but OON, may be higher than the in-network cost-sharing charged

by the plan for the services. This guidance is summarized in Table VI.

Table VI: Summary of Dialysis Cost-sharing.

Cost-sharing for dialysis

In-network

Out-of-network

In service area

May be higher than the in-

network, in service area cost-

sharing

Out of service area

Must be the same as in-

network, in service area cost-

sharing

Must be the same as in-

network, in service area cost-

sharing

Post-Stabilization Services: The cost-sharing amount for post-stabilization services must

be the same or lower for out-of-network providers as for in-network plan providers.

50.2 – Cost-sharing for In Network Preventive Services

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MA plans are required to cover without cost-sharing all in-network Medicare-covered

preventive services for which there is no cost-sharing under original Medicare (42 CFR

§422.100(k)). Plans are responsible for monitoring CMS’ National Coverage

Determinations and publications in order to ensure they are offering, in a timely manner,

all Medicare Part A and Part B services, including the zero cost-sharing preventive

services.

MA plans may not charge for facility fees, professional services, or physician office visits

if the only service(s) provided during the visit is a preventive service that is covered at

zero cost-sharing under original Medicare. However, if during provision of the preventive

service, additional non-preventive services are furnished, then the plan’s cost-sharing

standards apply.

Enrollees of a plan may directly access (through self-referral to any plan participating

provider) in-network screening mammography and influenza vaccine.

Please see section 90 of this chapter for information on National Coverage

Determinations (NCDs) which describes the requirements for plan compliance with new

NCDs, as well as website resources for monitoring NCDs.

50.3 – Total Beneficiary Cost (TBC)

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

As provided under section 1854(a)(5)(C)(ii) of the Affordable Care Act, and regulations

at 42 CFR §422.256(a), CMS may deny bids if CMS determines that a bid proposes too

significant an increase in cost-sharing or decrease in benefits from one plan year to the

next. CMS uses the Total Beneficiary Cost (TBC) metric as a means of evaluating

changes in plan benefits from one year to the next, and evaluating whether such changes

impose significant increases in cost-sharing or decreases in benefits. The change in TBC

from one year to the next captures the combined financial impact of premium changes

and benefit design changes (i.e., cost-sharing changes) on plan enrollees; an increase in

TBC is indicative of a reduction in benefits. By limiting the change in the TBC from one

year to the next, CMS is able to ensure that enrollees are not exposed to significant cost

increases from one plan year to the next. Annually, CMS provides TBC requirements and

operational information to plans through the Call Letter and other guidance documents.

50.4 – Single Deductible Rules for Regional and Local PPOs

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

A single deductible is a specified dollar amount to be paid annually by the enrollee for

health care services or for covered Part D drugs before the plan begins to pay its share of

the cost for those benefits. The single deductible amount may apply to all plan services or

to specific categories of plan services with the exception of emergency or urgently

needed services.

Plans may not charge enrollees the plan-level deductible prior to receiving Emergency

Care/Urgently Needed Services and the cost sharing for those services must always

contribute to satisfying the MOOP. Plans may count Emergency Care/Urgently Needed

Services cost sharing towards the plan-level deductible or plans may choose to not have

enrollee cost sharing count towards the plan-level deductible. However, plans must apply

this policy uniformly across the entire plan and marketing materials provided to

enrollees must be transparent regarding whether or not cost sharing applies toward the

plan-level deductible.

In addition to the applicable cost-sharing requirements listed in section 50.1 above, both

local and regional PPOs that choose to charge a deductible must establish a single

deductible that applies to services furnished in-network and out-of-network (OON). The

local or regional PPO may:

• Not apply the deductible to in-network $0 cost-share preventive services, but may

exempt any or all other in-network Medicare Part A and Part B services from the

deductible; that is, the regional or local PPO may choose to cover specific in-network

items or services at plan cost-sharing levels whether or not the single deductible has

been met;

• Charge different dollar amounts that count toward the single deductible for specified

Medicare Part A and Part B services furnished in-network;

• Exempt the OON $0 cost-share preventive services from the plan deductible.

However, plans may not exempt from the single deductible any other OON Medicare

Part A and Part B services; and

• Choose whether to require that the single deductible applies to non-Medicare covered

services (optional and mandatory supplemental benefits) furnished either IN or OON.

Example: A local or regional PPO charges a single deductible of $1,000. The plan limits

the application and amount of the deductible to IN inpatient hospital services ($500) and

IN physician services ($100). Additionally, the MA plan exempts Medicare covered

OON $0 preventive services from the deductible.

Analysis: The local or regional PPO in this example, complies with the PPO deductible

guidance because it:

• Charges a single plan deductible;

• Has elected to differentiate the applicability of this single deductible for two in-

network Medicare Part A and Part B services (Inpatient hospital and physician

services); and

• Does not exempt from the single deductible any Medicare Part A or B benefits

furnished out-of-network.

50.5 – Guidance on Other Enrollee Out-of-Pocket Liability

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Missed Appointment and Other Charges: MA plans may charge "administrative fees" to

enrollees for missed appointments with contracting providers and for not paying

contracting providers required cost-sharing at the time of service.

Under the MA program, such charges are allowable only if the charge is priced in the bid

and documentation submitted with the bid clearly shows these charges. Furthermore,

those additional charges must be clearly outlined in the notes section of the PBP and in

the Evidence of Coverage and ANOC, as applicable.

Contracted and non-contracted providers may charge a fee for missed appointments,

provided such fees apply uniformly to all Medicare and non-Medicare patients. This

applies even if the MAO itself does not charge an administrative fee for missed

appointments.

Neither MA plans nor their contracted providers may require enrollees to create a fund or

‘escrow account’ for a provider to ensure payment of missed appointment fees. Such a

practice creates a barrier to access to care and violates CMS anti-discrimination

regulations.

No balance billing: As indicated in section 170 below, an enrollee is responsible for

paying non-contracted providers only the plan-allowed cost-sharing for covered services.

The MA plan, not the enrollee, is obligated to pay balance billing when it is allowed

under Medicare rules. Furthermore, if an enrollee inadvertently paid balance billing

which is the plan’s responsibility, the plan must refund the balance billing amount to the

enrollee.

No reimbursement relationship: Plans may not require enrollees to pay a contracted

provider more than the plan’s specified cost-sharing for Part A and Part B services; that

is, plans may not require enrollees to pay the plan’s share of the costs for a service and

then reimburse the enrollee.

50.6 – Cost Sharing for Dual-Eligible Enrollees Requiring an Institutional

Level of Care

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

As provided under section 1860D-14 of the Act, Full Medicaid institutionalized

individuals have no cost sharing for covered Part D drugs under their PDP or MA-PD

plan. Effective January 1, 2012, section 1860D-14 of the Act also eliminates Part D cost

sharing for Full Medicaid individuals who would be institutionalized if they were not

receiving home and community-based services (HCBS) either through:

• A HCBS waiver authorized for a state under section 1115 or subsection (c) or (d)

of section 1915 of the Act;

• A Medicaid State Plan Amendment under section 1915(i) of the Act; or

• A Medicaid managed care organization with a contract under section 1903(m) or

section 1932 of the Act.

A SNP must determine or an enrollee must demonstrate that s/he is a Full Medicaid

individual receiving HCBS under title XIX with the following:

• A copy of a state-issued Notice of Action, Notice of Determination, or Notice of

Enrollment that includes the enrollee’s name and HCBS eligibility date during a

month after June of the previous calendar year;

• A copy of a state-approved HCBS Service Plan that includes the enrollee’s name

and effective date beginning during a month after June of the previous calendar

year;

• A copy of a state-issued prior authorization approval letter for HCBS that

includes the enrollee’s name and effective date beginning during a month after

June of the previous calendar year; or

• Other documentation provided by the state showing HCBS eligibility status

during a month after June of the previous calendar year.

See chapter 16b of the MMCM, “Special Needs Plans” for more information on dual

eligible enrollees, SNPs, and D-SNPs at https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/mc86c16b.pdf.

60 – Meaningful Difference

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The guidance in this section applies to non-employer MA and MA-PD plans of all types.

CMS reserves the right to extend the guidance in this section to employer plans in future

years.

As provided under 42 CFR §422.254(a) (5) and §422.256(b)(4)(i), CMS annually reviews

bids to ensure that an MAO’s plans in a given service area are meaningfully different

from one another in terms of key benefits or plan characteristics. Although the specific

guidelines and criteria for meaningful difference may change, the criteria CMS may use

to make this determination include:

• Cost-sharing: CMS sets a minimum differential in enrollees’ expected out-of-pocket

spending between an MAO’s plans of the same type in a service area;

• Mandatory supplemental benefits offered;

• Plan type;

• Inclusion of a Part D benefit (i.e., MA plan is meaningfully different from an MA-

PD); and

• Premiums.

CMS annually publishes guidelines to assist MAOs in creating plan designs in a given

area with meaningful differences. MAOs offering more than one plan in a given service

area should ensure that enrollees can easily identify the differences in benefit coverage

between the plans. Beneficiaries should be able, for example, to determine which plan

provides the highest value based on their needs. Plan bids that CMS determines are not

meaningfully different during the annual CMS review of submitted plan bids will not be

approved and MAOs will be required either to withdraw or consolidate such offerings.

Example: An MAO offers three plans in a service area with the characteristics listed

below. Since each plan differs from the other two plans by one of the characteristics

described above, this MAO is considered to be offering plans with meaningful

differences;

• Non SNP, MA-only;

• Non SNP, MA-PD; and

• SNP, MA-PD.

70 – Non-Renewal Based on Low Enrollment

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The guidance in this section applies to non-employer MA plans, including SNPs. CMS

may review employer plans for low enrollment in future years.

Pursuant to 42 CFR §422.514, CMS may not enter into or renew an MA contract with an

organization unless the organization has enrollment of at least:

(1) 5,000 individuals (or 1,500 individuals if the organization is a PSO)

are enrolled for the purpose of receiving health benefits from the

organization; or

(2) 1,500 individuals (or 500 individuals if the organization is a PSO) are

enrolled for purposes of receiving health benefits from the organization and

the organization primarily serves individuals residing outside of urbanized

areas as defined in §412.62(f) (or, in the case of a PSO, the PSO meets the

requirements in §422.352(c)).

However, a waiver of this enrollment may be provided at the time of an initial contract or

for the first three years the MA plan is offered. CMS will consider the experience of the

organization, its management personnel and its providers; the administrative and

marketing abilities of the organization; and the financial solvency and resources of the

organization in determining whether the organization is capable of administering and

managing an MA contract and is able to manage the level of risk required under the

contract to grant a waiver.

As provided under 42 CFR §422.506(b)(1)(iv), CMS may non-renew MA plans that have

an insufficient number of enrollees to be considered a viable plan option. Prior to bid

submission, CMS annually provides MAOs with criteria CMS uses to identify low

enrollment plans and contacts those MAOs that offer plans in the current contract year

that are identified as having low enrollment. The MAOs are instructed to either give

notice that they are terminating or consolidating the low enrollment plan(s), or submit,

within acceptable timeframes, a justification for continuing the plan(s). CMS will review

the submitted justifications and make a final decision on the continuation of the plan(s)

for the next contract year.

Determining whether an MA plan has sufficient enrollment to remain or be a viable plan

option each year requires consideration of many factors, including overall enrollment in

the MA program and enrollment in individual plans. CMS will announce in the spring its

interpretation and parameters for applying the regulation. These will take into account,

in addition to enrollment, the following:

• The number of years the plan has been in operation; and

• Whether the plan is a SNP.

80 – Value-Added Items and Services (VAIS)

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

80.1 – Definition and Requirements

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Value-Added Items and Services (VAIS) are items and services that are not plan benefits,

are not part of the MAO plan’s benefit package and may not be marketed to prospective

enrollees, or used as an inducement or incentive for enrollment. VAIS are non-Medicare

covered services or items, typically discounts, offered by a VAIS provider to the

enrollees of an MA plan. The plan may choose to facilitate access for its enrollees to the

VAIS by acting on behalf of the VAIS provider by performing certain administrative

activities, such as notifying enrollees about the VAIS or verifying enrollee membership

in the plan.

Thus, the MAO incurs either no cost for facilitating enrollees’ access to the VAIS, or the

costs are solely administrative. Solely administrative costs are defined as those required

to administer the plan’s facilitation of enrollee access to the VAIS, e.g., clerical items or

equipment and supplies related to communication about the VAIS (such as phone and

postage) or database administration (such as verifying enrollment or tracking utilization).

Minimal cost, in and of itself, does not qualify a cost as being “solely administrative.”

It is important to note the following:

• Plan enrollees who choose to obtain VAIS items or services are responsible for all

costs.

• Any notification a plan sends to its enrollees about the availability of VAIS must

include a disclaimer explaining that the VAIS is not a plan benefit.

• MAOs may not include VAIS in any marketing materials.

• VAIS is not an alternative to a supplemental benefit. That is, if CMS determines that

a specific item or service for which the plan would incur more than administrative

cost, is not allowable as a supplemental benefit, the plan may not offer the item or

service as a VAIS.

An MAO is expected to comply with the following related to VAIS:

• Offer the VAIS for the entire contract year;

• Offer the VAIS uniformly to all plan enrollees;

• Maintain the privacy and confidentiality of enrollee records in accordance with all

applicable statues and regulations;

• Comply with all applicable fraud and abuse laws, including the anti-kickback statute

and prohibition on inducements to enrollees;

• Not price the VAIS in the plan bid;

• Costs incurred, if any for the VAIS, are solely administrative;

• Clearly include a disclaimer in any material provided to enrollees about the VAIS that

the VAIS is not a part of the plan’s benefits; and

• Only offer the VAIS to plan enrollees. Dependents, spouses and other non-plan

enrollees are not permitted to receive VAIS through the MAO.

Note: Although VAIS may not be included in the plan bid, CMS may review a plan’s

VAIS in its audit of the plan or in response to enrollee complaints related to the VAIS.

80.2 – Explanatory Examples

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

The following are some examples of CMS’ approach to VAIS:

• Example 1: In addition to a plan covering an in-network mandatory supplemental

routine vision exam benefit (for which the plan incurs a direct medical cost), it offers

as a VAIS a 5% discount on a routine vision exam furnished by an out-of-network

vision center. The plan does not incur any medical cost for the out-of-network exam,

but does incur some administrative cost to verify enrollee plan membership for the

discount and to inform its enrollees about the 5% discount.

Analysis: Because the plan does not incur any medical cost in offering the discount

for the routine vision exam out-of-network, by definition, the discount cannot be

classified as a benefit, and is therefore, eligible to be offered as a VAIS. Furthermore,

because the out-of-network routine vision exam is a VAIS, it may neither be

advertised to prospective enrollees nor included in the plan bid.

• Example 2: An MA plan wishes to offer vouchers for free groceries to its enrollees

for which it incurs a minimal cost.

Analysis: Grocery vouchers may not be offered as a VAIS if the plan incurs a cost for

the vouchers. Although the cost may be minimal, it is not solely administrative and

therefore, is not consistent with CMS guidance.

• Example 3: An MA plan contracts with a provider or another insurer, such as an

insurer for dental or vision services, to furnish non-Medicare covered benefits to its

enrollees at a reduced cost. The provider or insurer requires the plan to collect and

aggregate payments from its enrollees and to send those payments to the provider or

insurer.

Analysis: MA plans must include in the plan benefit package all benefits it furnishes

by way of a contract with a provider or insurer on behalf of its enrollees and may not

contract to offer such a benefit as a VAIS. The plan may not collect payments from

its enrollees for services that are not benefits covered by the plan.

However, if the provider or insurer in the example offers its services at a discounted rate

to the MA plan enrollees, who directly pay the provider or insurer for the services,

without additional payment from the plan, then the plan may provide access to this

discount as a VAIS.

90 – National and Local Coverage Determinations

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

90.1 – Overview

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs are expected to stay apprised of new and/or changing Medicare Part A and Part B

coverage policies, including those that result from CMS’s National Coverage

Determination (NCD) process. Information regarding NCDs is continuously updated on

the CMS website at: http://www.cms.hhs.gov/center/coverage.asp. See section 90.6 of

this chapter for a list of CMS website sources containing information.

As discussed in section 10.2 of this chapter, an item or service classified as an original

Medicare benefit must be covered by every MA plan if:

• Its coverage is consistent with general coverage guidelines included in original

Medicare regulations, manuals and instructions (unless superseded by written CMS

instructions or regulations regarding Part C of the Medicare program);

• It is covered by CMS’ national coverage determinations (see sections 90.3 and 90.4,

below); or

• It is covered by written coverage decisions of local Medicare Administrative

Contractors (MACs) with jurisdiction for claims in the geographic area in which

services are covered under the MA plan, as described in section 90.2 below.

90.2 – Definitions Related to National Coverage Determinations (NCDs)

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

The contents of this section are governed by statutes and regulations including those set

forth at 42 CFR §422.109. The following definitions related to national coverage

determinations apply:

• A National Coverage Determination (NCD) is a determination by the Secretary

with respect to whether or not a particular item or service is covered under Medicare.

An NCD does not include a determination of what code, if any, is assigned to a

service or a determination about the payment amount for the service. HCPCS and

other codes are assigned through separate guidance.

• An NCD is issued under procedures that are established in the Federal Register and is

published in the Medicare National Coverage Determination (NCD) manual. Each

NCD will contain a specific effective date.

• A legislative change in benefits is a coverage requirement adopted by the Congress

and mandated by statute. The Secretary of Health and Human Services generally

implements a legislative coverage change through regulation and/or sub-regulatory

guidance.

• The term significant cost, as it relates to a particular NCD or legislative change in

benefits, means either of the following:

o The average cost of furnishing a single service exceeds a cost threshold that for a

calendar year is the preceding year’s dollar threshold adjusted to reflect the

national per capita growth percentage described at 42 CFR §422.308(a); or

o The estimated cost of Medicare services furnished as a result of a particular NCD

or legislative change in benefits represents at least 0.1 percent of the national

average per capita costs.

90.3 – General Rules for NCDs

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Medicare coverage policies specify which items and services are covered (or not covered)

under Part A or Part B of the Medicare program and under what circumstances (including

the clinical criteria under which the item or service must be covered). Medicare coverage

policies have several sources:

• NCDs made by CMS;

• Local Coverage Determinations (LCDs);

• Legislative changes in benefits applied through notice and comment rulemaking

(often codifying the changes in the Code of Federal Regulations); and

• Other coverage guidelines and instructions issued by CMS (e.g., Change requests and

Program Transmittals).

As indicated in section 10.2 above, MA plans must provide all items and services

classified as original Medicare-covered benefits. In applying this rule to NCDs, different

rules apply depending on whether the significant cost criterion, described above in

section 90.3, has been met.

90.3.1 – When the Significant Cost Criterion is Not Met

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

When CMS determines that a NCD or legislative change in benefits does not meet a

criterion for significant cost, the MA plan is required to provide coverage for the NCD or

legislative change in benefits and assume risk for the costs of that service or benefit as of

the effective date of the NCD or as of the date specified in the legislation/regulation.

NCDs are effective on the date that CMS releases the Final Decision Memorandum for

the NCD. The NCD effective date is the date when the new or changed benefit/service

must be made available to enrollees by the plan. The implementation date in the

corresponding Medicare Change Request (CR) /Transmittal guidance (TR) is the latest

date by which MA plans must have payment system edits in place and coverage/non-

coverage fully implemented for providers/suppliers. Plans must ensure that the

items/services are covered, and provider claims paid, retroactive to the NCD effective

date. More information related to Medicare CR/TRs and manual guidance may be found

in references provided in section 90.6 below.

90.3.2 – When the Significant Cost Criterion is Met

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

Prior to the adjustment of the annual MA capitation rate, if CMS determines and

announces that an individual NCD item, service or legislative change in benefits does

meet a criterion for significant cost, then plans are not required to assume risk for the

costs of that service or benefit until the contract year for which payments are

appropriately adjusted to take into account the significant cost of the service or benefit.

However, a plan must pay for the following:

• Diagnostic services related to the NCD item, service, or legislative change in benefits

and most follow-up services related to the NCD item, service, or legislative change

(42 CFR § 422.109(c)(2)(i),(ii));

• NCD items, services, or legislative change to benefits that are already included in the

plan’s benefit package either as original Medicare benefits or supplemental benefits.

Although the item or service may not be specifically included in the services MAOs must

cover under their contract with CMS, MAOs must still provide access to the NCD item or

service by furnishing or arranging for the service.

The MACs are responsible for reimbursements for NCD items, services, or legislative

changes that are not the legal obligation of the MAO.

90.3.3 – Payment for NCD Items and Services

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Chapter 8 of the MMCM, “Payments to Medicare Advantage Organizations,” contains the

detailed rules on payment for NCD items and services or legislative changes in benefits

that meet the significant cost threshold. That manual chapter includes a description of

services for which MAOs are responsible. Enrollees are responsible for any applicable

coinsurance amounts under original Medicare.

Once the annual MA capitation rate, or other payment adjustment, reflects the new costs,

the service or benefit is considered included in the MAO’s contract with CMS and is a

covered benefit under the contract. The MAO must furnish, arrange, or pay for the NCD

service or legislative change in benefits, subject to all applicable rules. MAOs may

establish separate plan rules for these services and benefits, subject to CMS review and

approval. CMS may, at its discretion, issue overriding instructions limiting or revising the

MA plan rules, depending on the specific NCD or legislative change in benefits. For

these services or benefits, the enrollee is responsible for any MA plan cost-sharing, as

approved by CMS or unless otherwise instructed by CMS.

90.4 – Local Coverage Determinations (LCDs)

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

90.4.1 – MAC with Exclusive Jurisdiction over a Medicare Item or

Service

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

In some instances, one Medicare A/B MAC processes all of the claims for a particular

Medicare-covered item or service for all Medicare beneficiaries around the country. This

generally occurs when there is only one provider of a particular item or service (for

example, certain pathology and lab tests furnished by independent laboratories). In this

situation, MA plans must follow the coverage policy reflected in an LCD issued by the

A/B MAC that enrolled the provider and processes all of the Medicare claims for that

item or service.

90.4.2 – Multiple A/B MACs with Different Policies

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

When there are multiple A/B MACs that have different coverage policies in an MA

plan’s service area, the MA plan must choose from the following alternatives for its

coverage policy. Note: All DME MACs have the same LCDs; therefore, there should not

be differences related to DME coverage in a plan’s service area.

Local Plans:

1. A local MA plan may choose to adopt the coverage policy that applies to original

Medicare beneficiaries. In this alternative, the coverage policy that applies to plan

enrollees will be that of the A/B MAC with jurisdiction over the state in which the

service is furnished to the enrollee.

2. A local MA plan that chooses to adopt a uniform coverage policy that will apply

uniformly to all plan enrollees, may choose the A/B MAC coverage policy

applicable in its service area that is the most beneficial to enrollees.

• The MA plan must make information on the selected coverage policy

determinations readily available, including through the plan’s website, to all

enrollees and health care providers; and

• The MAO must notify CMS, through its account manager, 60 days before the

date bids are due, if it elects to adopt a uniform local coverage policy for any

plan or plans in the subsequent year (42 CFR § 422.101(b)(3)(i)). In preparing

this notification, the MAO should include, at a minimum:

o An identification of the plan(s) and service area(s) to which the uniform

local coverage policy or policies will apply;

o The competing local coverage policies involved; and

o A table contrasting the local coverage areas by listing and comparing

those policies in each coverage area that represent expansions of Medicare

Part A and Part B services.

CMS will review notices provided to evaluate the selected policy or policies on

the bases of cost, access, geographic distribution and health status of enrollees.

CMS will notify the MAO of its approval or denial of the selected uniform local

coverage policy or policies.

Regional Plans:

1. A regional MA plan may choose to adopt the coverage policy that applies to

original Medicare beneficiaries. In this alternative, the coverage policy that

applies to plan enrollees will be that of the A/B MAC with jurisdiction over the

state in which the service is furnished to the enrollee or

2. A regional MA plan that chooses to adopt a uniform coverage policy must select

one of the A/B MACs with jurisdiction in the plan service area and apply the

policies of that A/B MAC uniformly to all enrollees of the plan.

• Plans must make information on the selected local coverage policy

determinations readily available, including through the plan’s website, to all

enrollees and health care providers.

• Regional MA plans may not select local coverage policies from more than one

A/B MAC and selection of the coverage policy is not subject to CMS pre-

approval (42 CFR § 422.101(b)(4)) but must notify CMS, through their

account managers, 60 days before the date bids are due, if the plan elects to

adopt a uniform local coverage policy for any plan or plans in the subsequent

year (42 CFR § 422.101(b)(3)(i)). In preparing this notification, plans should

include, at a minimum:

o An identification of the plan(s) and service area(s) to which the uniform

local coverage policy or policies will apply;

o The competing local coverage policies involved; and

o A table contrasting the local coverage areas by listing and comparing

those policies in each coverage area that represent expansions of Medicare

Part A and Part B services.

Note: If a local or regional MA plan adopts a uniform coverage policy as indicated above,

that uniform coverage policy only applies to its service area. Services for an enrollee

from a provider outside the service area are covered based on the local coverage

determinations of that provider’s geographic location.

90.5 – Creating New Guidance

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

In coverage situations where there is no NCD, LCD, or guidance on coverage in original

Medicare manuals, an MAO may adopt the coverage policies of other MAOs in its

service area.

However, if the MAO decides not to use coverage policies of other MAOs in its service

area, the MAO:

• Must make its own coverage determination;

• Must provide CMS an objective evidence-based rationale relying on authoritative

evidence such as:

o Studies from government agencies (e.g. the FDA);

o Evaluations performed by independent technology assessment groups (e.g.

BCBSA); and

o Well-designed controlled clinical studies that have appeared in peer review

journals; and

• In providing its justification, the MAO may not use conclusory statements with no

accompanying rationale (e.g., “It is our policy to deny coverage for this service.”)

The requirement that an MA plan provide coverage for all Medicare-covered services is

not intended to dictate care delivery approaches for a particular service. MA plans may

encourage enrollees to see more cost-effective provider types than would be the typical

pattern in original Medicare, as long as those providers are licensed and working within

the scope of their licenses and the plan complies with the provider anti-discrimination

rules set forth in 42 CFR §422.205.

An MA plan’s flexibility to deliver care using cost-effective approaches should not be

construed to mean that Medicare coverage policies do not apply to the MA program. If

original Medicare covers a service only when certain conditions are met, then such

conditions must be met in order for the service to be considered part of the original

Medicare benefits component of an MA plan. An MA plan may cover the same service

when the conditions are not met, but these benefits would then be defined as

supplemental.

90.6 – Sources for Obtaining Information

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

Generally, legislative changes to Medicare coverage rules are established by statute and

implemented through notice-and-comment rulemaking. For example, if Medicare Part B

coverage is affected, the changes are usually included in the annual Medicare Physician

Fee Schedule (MPFS) proposed and final rules, published in the Federal Register every

summer and fall, respectively. These rules are codified in the Code of Federal

Regulations. Medicare manual guidance corresponding to legislative changes in benefits

may also be released in the Medicare Benefit Policy Manual (Pub. 100-02) and/or the

Medicare Claims Processing Manual (Pub. 100-04).

Implementation of coverage changes resulting from the NCD process and all related

changes to original Medicare claims processing are made through Change Requests

(CRs) and Transmittals (TRs) that also are used to update the Medicare National

Coverage Determinations Manual (Pub. 100-03) and the Medicare Claims Processing

Manual (Pub. 100-04).

Although MA plans have not been required to use original Medicare claims processing

systems, MAOs must follow the coverage instructions in the original Medicare CRs/TRs.

We also encourage plans to use claims processing guidance as a source of information

that will support their implementation of the new benefit/service or other change in

coverage.

The following Internet resources provide information on NCDs and LCDs:

The Medicare Coverage webpage located at:

http://www.cms.hhs.gov/center/coverage.asp has links that:

• Provide a listing of all NCDs;

• Provide a listing of all National Coverage Analyses (NCAs) and final Decision

Memos;

• Provide an index of Local Coverage Determinations (LCDs);

• Enable users to subscribe to the CMS Coverage Listserv and receive weekly

notifications when national coverage documents are updated, such as national

coverage analyses (NCAs) and national coverage determinations (NCDs). Listserv

subscribers also receive special updates, including CMS announcements of new

topics opened for national decision, posting of decision memos, and posting of final

technology assessment (TA) reports;

• Provide a list of all email coverage updates sorted by year; and

• Enable users to search the database.

Both pending and closed coverage determinations are listed. For each coverage topic

CMS provides a staff name and e-mail link so that interested individuals can send

questions and provide feedback.

The Medicare National Coverage Determinations Manual, Publication 100-03,

accessible at: http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html, includes the Medicare

national coverage determinations.

Program Transmittals and Change Requests transmit CMS’ new policies and

procedures on new coverage determinations and Medicare benefits. Links to the Program

Transmittals and Change Requests can be found at http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/index.html; and

Medicare Internet-Only Manuals, located at http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html. These manuals,

including the Benefit Policy Manual and Claims Processing Manuals, as described above,

present information on Medicare coverage of items and services and claims processing.

Changes to these manuals are released through Program Transmittals and Change

Requests.

100 – Rewards and Incentives

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

An MA plan may create one or more Rewards and Incentives (RI) Programs that provide

rewards and/or incentives to enrollees in connection with participation in activities that

focus on promoting improved health, preventing injuries and illness, and promoting

efficient use of health care resources. The overall goal of RI Programs is to encourage

enrollees to be actively engaged in their health care and, ultimately, improve and sustain

their overall health and well-being.

An RI Program incentivizes an enrollee to participate in health-promoting services or

activities while inspiring a long-term commitment to healthy behaviors. Accordingly, in

addition to providing rewards and/or incentives, plans should consider including an

enrollee support component within their RI Program design (e.g., coaches or motivators

to encourage and assist the enrollee with RI Program engagement).

At this time, RI Programs apply only to Part C (Medicare Advantage) at 42 CFR §422

and may not be offered in connection with any Part D benefits governed by 42 CFR §423.

Pursuant to 42 CFR §422.134, each RI Program offered by an MA plan:

• Must not discriminate against enrollees based on race, gender, chronic disease,

institutionalization, frailty, health status or other impairments; and

• Must be designed so that all enrollees are able to earn rewards.

Rewards and incentives associated with the RI Program must:

• Be offered in connection with the entire service or activity;

• Be offered to all eligible enrollees without discrimination;

• Have a value that may be expected to affect enrollee behavior, but not exceed the

value of the health related service or activity itself; and

• Otherwise comply with all relevant fraud and abuse laws, including, when

applicable, the anti-kickback statute and civil money penalty prohibiting

inducements to enrollees.

Rewards and incentives associated with the RI Program may not:

• Be offered in the form of cash or other monetary rebates or

• Be used to target potential enrollees.

An RI Program is not a benefit. It must be included in the bid as a non-benefit expense

but must not be entered in the Plan Benefit Package. Per CMS Office of the Actuary

Bidding Guidance, “non-benefit expenses are all of the bid-level administrative and other

non-medical costs incurred in the operation of the MA plan.”

The timeframe for earning and redeeming rewards and/or incentives must be within the

contract year in which the RI Program has been implemented. In order to prevent the use

of rewards as motivation to stay in a plan, RI Programs may not allow enrollees to carry

over rewards and/or incentives from one contract year to the next.

100.1 – Health-Related Services and Activities

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MA plans have significant flexibility in designing RI Programs that are specific to their

populations’ interests, abilities and needs. Plans are free to determine the specific

services, activities, or behaviors that are subject to rewards or incentives within their RI

Program design. Health-related services and activities associated with an RI Program

may include, for example, the utilization of a particular service(s) or preventive

screening benefit(s), adherence to prescribed treatment regimens, attending

education/self-care management lessons, meeting nutritional goals, and making and

keeping appointments with the doctor.

Plans may not discriminate based on health status, therefore, rewards and incentives

based on health outcomes may not be offered. However, enrollees may be rewarded for

continued healthy behaviors over time. For example, plans may not provide rewards and

incentives for the amount of weight lost or a lowered blood pressure, as those are health

outcomes and health status factors. Instead, the plan may provide rewards and/or

incentives to enrollees for reporting their weights or blood pressures at regular intervals.

Plans also may reward sustained behavior changes by enrollees in order to support and

promote the ultimate goal of RI Programs, which is lasting, positive changes in health-

related behaviors. For example, an RI Program might include rewards and incentives for

those enrollees that report that they remain smoke-free at several time intervals after

completion of a smoking cessation program.

Note: Completion of a federally mandated survey, though arguably a health-related

activity, may not be included in an RI Program because of the potential for biased

responses due to the influence of rewards or incentives.

100.2 – Non-discrimination

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Any RI Program offered by an MA plan must not discriminate against enrollees based on

race, gender, chronic disease, institutionalization, frailty, health status or other

impairments and must be designed so that all enrollees are able to earn rewards.

The non-discrimination and equal access requirements do not preclude plans from

offering RI Programs that target enrollees with a specific disease or chronic condition as

long as the RI Program does not discriminate against any enrollee who would otherwise

qualify for participation. Thus, any RI Program must accommodate otherwise qualified

enrollees who receive services in an institutional setting or who need a modified

approach to enable effective participation and attainment of designated rewards and

incentives.

For example, while internet-based RI Programs are allowed, an alternate method of

earning and/or claiming rewards and incentives must be offered to those enrollees who

do not have internet access. Another example is an RI Program in which participants

earn a reward for participating in an exercise class. An alternate method of fulfilling an

exercise activity must be offered to those individuals who are unable to attend the class,

perhaps due to institutionalization, lack of transportation, or are disabled or wheelchair

bound.

A caretaker may not participate in place of the enrollee in the services or activities in

order to earn rewards or incentives on behalf of the enrollee. The goal of an RI Program

is to encourage and maintain healthy behaviors that have a positive impact on enrollees;

therefore, the enrollee must participate directly in the RI Program.

All RI Programs must provide the same rewards to all qualifying participants who

perform the same action(s). An RI Program may not distinguish enrollees based on their

medical encounter history. In other words, plans may not reward enrollees who have

historically not utilized appropriate/recommended services at a higher level than other

enrollees for participating in a RI Program activity. While RI Programs may aim to

encourage more participation in preventive care, they may not discriminate against

enrollees who have a good record of participation.

100.3 – Offering Rewards In Connection With the Entire Service or

Activity

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Within an RI Program, rewards and incentives must be earned by completing an entire

service or activity (or combination of services/activities), as established by the MA plan,

and may not be offered for completion of less than any/all required component(s) of the

eligible service or activity. This requirement allows CMS and MA plans to interpret the

value of a reward or incentive in relation to the service or activity for which it is being

offered.

Plans are expected to reasonably define the scope of the “entire service or activity”

within their RI Program design and assign a value of the reward or incentive

accordingly. For example, a plan may decide to offer rewards and/or incentives for

participation in a smoking cessation program. The plan may decide to give smaller

rewards for each class or counseling session attended or may offer a single, larger

reward for completing a pre-determined number of classes or counseling sessions.

Consistent with the requirement that rewards and incentives be of a value that may be

expected to affect enrollees’ behavior, the service or activity for which rewards and/or

incentives are being offered should be at a level that is meaningful.

100.4 – Valuing Rewards and Incentives

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Rewards and incentives for each RI Program must have values that are expected to elicit

intended enrollee behavior but may not exceed the value of the health related service or

activity (§422.134(C)(1)(iii)).

At this time, CMS has not identified the monetary values that exceed what is necessary to

influence enrollee behavior. There is also no express limit on how often rewards and/or

incentives may be offered to enrollees throughout a contract year. Instead, MA plans are

to establish reasonable and appropriate values for rewards and/or incentives that comply

with §422.134.

If necessary, in the future, we may issue additional guidance applying the regulation

standards to specify limits on the value of rewards and incentives.

100.5 – Permissible Rewards and Incentives

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Rewards and/or incentives may not be offered in the form of cash or monetary rebates,

including reduced cost-sharing or premiums. Otherwise, MAOs have considerable

flexibility with regard to what may be offered as a reward or incentive.

Gift cards are a permissible form of reward or incentive as long as they are not

redeemable for cash. MA plans are encouraged to offer enrollees a choice of gift cards

from which to choose in order to account for differences in enrollees’ preferences and

accessibility of retailers.

Discount coupons are also a permissible form of reward or incentive as long as they are

not transferable for cash and follow the valuing guidelines addressed above. However,

we would note that coupons that provide only nominal discounts may not provide

adequate incentive to drive the intended changes in enrollee behavior and thus not align

with CMS valuing guidelines.

An RI Program that is designed so that enrollees earn “points” or “tokens” that can be

used to “purchase” rewards (or some variation of this type of program) is permissible as

long as the “points” and the rewards that may be “purchased” are earned and valued

(according to CMS guidelines as set forth within this guidance and in accordance with

§422.134) and are redeemed during the contract year in which they are earned.

Rewards and/or incentives must be tangible items that align with the purpose of the RI

Program and must directly benefit the enrollee. For example, a plan’s charitable

contribution made on behalf of the enrollee does not satisfy the CMS criteria as a

permissible reward or incentive because the enrollee who earned the reward does not

benefit from such a contribution by the plan. However, the use of points (which are not

themselves tangible), to purchase a reward, does satisfy CMS criteria because the points

are used by each enrollee to obtain a tangible reward that is of value to the enrollee.

Rewards and/or incentives that are to be won based on probability, including programs

in which an enrollee may earn entries into a lottery or drawing in order to receive a

reward or incentive of a significant value, are not permissible because all enrollees who

participate in and complete the services or activities required of them within the RI

Program’s design must receive a tangible reward and incentive. The potentially

negligible chance of winning the reward in such a scheme (depending on the pool of

eligible enrollees) does not qualify as a tangible reward or incentive. Furthermore, RI

Programs structured in this manner are potentially vulnerable to fraud and abuse

implications.

100.6 – Marketing RI Programs

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MA plans may include information about RI Programs in marketing materials as long as

those communications are provided to all current and prospective enrollees without

discrimination. Additionally, any marketing of RI Programs must be done in conjunction

with marketing of plan covered benefits.

Importantly, reward and/or incentive “items” may not be offered to potential enrollees

under any circumstances. Nominal gifts as part of promotional activities are separate

and distinct from RI Programs. For more information about the marketing aspects of RI

Programs as well as promotional activity guidance, see the Medicare Marketing

Guidelines at https://www.cms.gov/Medicare/Health-

Plans/ManagedCareMarketing/FinalPartCMarketingGuidelines.html.

100.7 – Reporting to CMS

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MA plans will be required to report on RI Programs through the annual Part C Medicare

Advantage Reporting Requirements. MA plans offering an RI Program are expected to

document and track information regarding their RI Programs and be prepared to provide

that information to CMS upon request. Appropriate documentation includes, but is not

limited to: date(s) of enrollee-specific participation in RI Program services and activities,

rewards and/or incentives attained, how enrollee participation is measured, and

available alternative methods of participation.

PART II – BENEFICIARY PROTECTIONS

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Part II of this chapter, which begins in section 110, provides information on beneficiary

protections, and includes topics such as rules for plan renewals, coordination of benefits,

providers, provision of benefits during disaster situations, and educating and enrolling

enrollees in Medicaid and Medicare savings programs.

110 – Access to and Availability of Services

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

110.1 – Access and Availability Rules for Coordinated Care Plans

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

An MA plan may specify the providers through whom enrollees may obtain services if it

ensures that all original Medicare covered services and supplemental benefits contracted

for, by, or on behalf of Medicare enrollees are available and accessible under the

coordinated care requirements.

Plans are required to maintain and monitor a network of appropriate providers, supported

by written arrangements, that is sufficient to provide adequate access to covered services

to meet the needs of the population served. This involves ensuring that services are

geographically accessible and consistent with local community patterns of care. In other

words, the plan must ensure that contracted providers are distributed so that no enrollee

residing in the service area must travel an unreasonable distance to obtain covered

services. CMS standards for access are provided by the Health Service Delivery (HSD)

tables used to evaluate plan networks during the initial application, service area

expansion application, and continued operations throughout the contract year. The HSD

process uses a mostly automated process to measure access by county and specialty. The

assessment measures used include measuring the number of providers, as well as the

average distance and time needed for enrollees to access each provider and facility in

each county.

All MAOs are expected to continuously monitor their networks to ensure compliance with

contractual obligations and in accordance with 42 CFR 422.112(a)(1)(i). CMS

encourages MAOs to use the “organization-initiated” automated review feature in the

Network Management Module (NMM) in HPMS. For more information, please refer to

the December 23, 2015, HPMS memo “Release of Network Management Module in

Health Plan Management System (HPMS).”

In addition, as part of this continuous network self-monitoring, CMS expects that if an

MAO becomes aware of network deficiencies at any time or believes that an exception is

warranted for a particular specialty in a given service area, then the MAO will alert its

CMS Account Manager.

110.1.1 – Provider Network Standards

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs are required to establish and maintain provider networks that:

• Define the types of providers to be used when more than one type of provider can

furnish a particular item or service;

• Identify the types of mental health and substance abuse providers in their network;

• Specify the types of providers who may serve as an enrollee’s primary care physician;

• Are accurately reflected in up-to-date directories. Plans are responsible for verifying

and regularly updating their network directories to ensure that providers included in

the directories are available to their enrollees (i.e., listed providers accept new

patients who are enrolled in the plan). Please see section 110.2 below for more

information on provider directory updating requirements.

• Employ written standards for timeliness of access to care and member services that

meet or exceed such standards as may be established by CMS, make these standards

known to all first tier and downstream providers, continuously monitor its provider

networks’ compliance with these standards, and take corrective action as necessary.

These standards must ensure that the hours of operation of the plan’s providers are

convenient to, and do not discriminate against, enrollees. The plan must also ensure

that, when medically necessary, services are available 24 hours a day, 7 days a week.

This includes requiring primary care physicians to have appropriate backup for

absences. The standards should consider the enrollee’s need and common waiting

times for comparable services in the community. (Examples of reasonable standards

for primary care services are: (1) urgently needed services or emergency -

immediately; (2) services that are not emergency or urgently needed, but in need of

medical attention - within one week; and (3) routine and preventive care - within 30

days);

• Establish, maintain, monitor and validate credentials for a panel of primary care

providers from which the enrollee may select a personal primary care provider. All

MA plan enrollees may select and/or change their primary care provider within the

plan without interference. Plans that require enrollees to obtain a referral before

receiving specialist services typically require this referral be obtained from a primary

care provider. However, some enrollees do not select primary care providers.

Consequently, plans must ensure that there is a mechanism for assigning primary care

providers (for purposes of referral) to enrollees who do not select a primary care

provider;

• Regardless of the MA plan type being offered, arrange for medically necessary care

outside of the network, but at in-network cost-sharing, in order to provide all

Medicare Part A and Part B benefits. That is, if an enrollee requires a medically

necessary covered service that is not provided by the providers in the network, the

plan must arrange for that service to be provided by a qualified non-contracted

provider;

• Provide or arrange for necessary specialist care, and in particular give female

enrollees the option of direct access to a women’s health specialist within the network

for women’s routine and preventive health care services;

• Ensure that all services, both clinical and non-clinical, are provided in a culturally

competent manner and are accessible to all enrollees, including those with limited

English proficiency, limited reading skills, hearing incapacity, or those with diverse

cultural and ethnic backgrounds. Examples of how a plan may meet these

accessibility requirements include, but are not limited to provision of translator

services, interpreter services, teletypewriters, or TTY (text telephone or teletypewriter

phone) connection;

• Establish and maintain written standards, including coverage rules, practice

guidelines, payment policies and utilization management protocols that allow for

individual medical necessity determinations. These standards must be available to

both enrollees and providers. Section 90.5 of this chapter provides guidance and

criteria for formulating such standards;

• Provide coverage for ambulance services, emergency and urgently needed services,

and post-stabilization care services in accordance with the requirements in section 20

above; and

• Have a quality improvement program plan as outlined in chapter 5 of the MMCM.

The quality improvement program plan must include a Chronic Care Improvement

Program (CCIP) and a Quality Improvement Project (QIP).

Plans may not implement utilization management protocols that create inappropriate

barriers to needed care. Prior authorization and referral are two utilization management

approaches frequently used by plans and are entered in the PBP; the following

definitions and requirements clarify the meaning and appropriate use of these two

approaches:

• Prior Authorization: A process through which the physician or other health care

provider is required to obtain advance approval from the plan that payment will be

made for a service or item furnished to an enrollee. Unless specified otherwise with

respect to a particular item or service, the enrollee is not responsible for obtaining

(prior) authorization.

• Referral: A process through which the enrollee’s primary care physician or other

network physician (depending on the plan policy) permits or instructs the enrollee to

obtain an item or service from another physician or other provider type.

110.1.2 – Significant Changes to Networks

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

110.1.2.1 – General

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

When MAOs submit PBPs for CMS’ review and approval, they attest that the benefits

included in those packages “…will be offered in accordance with all applicable

Medicare program authorizing statutes and regulations and program guidance that CMS

has issued to date…” Thus, MAOs’ PBPs for the upcoming contract year must meet, and

continue to meet, CMS network adequacy standards, as outlined in the guidance in this

chapter and current MA HSD Network Adequacy Criteria Guidance, which can be found

on the MA Applications webpage at: https://www.cms.gov/MedicareAdvantageApps.

See 42 CFR §422.112(a)(1)(i).

MAOs have considerable discretion to select the providers with whom to contract in

order to build high-performing, cost effective provider networks. They are able to make

changes to these networks at any time during the contract year, as long as they continue

to furnish all Medicare-covered services in a non-discriminatory manner, meet

established access and availability standards and timely notice requirements, and ensure

continuity of care for enrollees.

CMS recognizes that significant no-cause network changes may occur during the

contract year. MAOs may be in the best position to determine whether or not a provider

termination without cause is significant. CMS considers significant changes to provider

networks to be those that go beyond individual or limited provider terminations that

occur during the routine course of plan operations and affect, or have the potential to

affect, a large number of the MAO’s enrollees.

Please note: Significant network changes could result from any no-cause provider

termination, whether it is initiated by the MAO or the provider. In addition, significant

network changes could result from no-cause provider terminations that are effective at

any point during the contract year, whether it is mid-year or on January 1.

110.1.2.2 – Notification to CMS

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

An MAO must notify its CMS Account Manager of any no-cause provider termination

that the MAO deems to be significant, at least 90 days prior to the effective date of the

termination. To the extent possible, CMS would like to ensure that appropriate

contingency planning is in place prior to an MAO making any significant network

change. For example, an MAO should notify its Account Manager if it is in current

contract negotiations with a provider group that would have a significant impact on the

network if the negotiations were not successfully concluded.

CMS expects MAOs to take a conservative approach in determining whether a network

change is significant by notifying CMS if there is any doubt as to whether the no-cause

provider termination represents significant change to the network. This prior notification

facilitates CMS oversight and verification of MAO compliance with current CMS network

adequacy standards.

An MAO that does not notify CMS of network changes that are

ultimately deemed significant will be subject to appropriate compliance actions.

Upon CMS notification, CMS may ask the MAO to provide additional information about

the network change, and CMS will verify whether the network change is indeed

significant. If CMS deems the MAO’s network change to be significant, then CMS may

ask the MAO to demonstrate its continued compliance with current CMS network

adequacy standards through the submission of HSD tables to the NMM.

CMS may also ask the MAO to submit a written plan that provides a detailed description of

the steps the MAO will take to ensure that affected enrollees are able to locate new providers

that meet their individual needs and describe how continuity of care would be maintained for

affected enrollees. MAOs would also provide, upon request, information about the number

and outcome of continuity of care requests that they receive so that CMS may confirm that

the MAO is in compliance with all applicable requirements.

In addition, CMS may require the MAO to augment its network by contracting with

additional providers to meet network adequacy standards or, if necessary in order to

meet immediate access needs, to allow enrollees to access care from non-contracted

providers and limit enrollee cost-sharing to in-network amounts. Furthermore, it may be

necessary for MAOs to allow care to continue to be furnished on an interim, transitional

basis, by providers who have been terminated from the network in order to adequately

address continuity of care needs for affected enrollees.

110.1.2.3 – Notification to Enrollees

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Pursuant to 42 CFR §422.111(e), when an MAO makes changes to its provider network,

the MAO must make a good faith effort to provide written notice of a termination of a

contracted provider at least 30 calendar days before the termination effective date to all

enrollees who are patients seen on a regular basis by the provider whose contract is

terminating, irrespective of whether the termination was for cause or without cause.

When a contract termination involves a primary care professional, all enrollees who are

patients of that primary care professional must be notified.

Please note that CMS considers “enrollees who are patients seen on a regular basis by

the provider whose contract is terminating” to be “affected enrollees.” An “affected

enrollee” as an enrollee who is assigned to, currently receiving care from, or has

received care within the past three months from a provider or facility being terminated.

When an MAO makes significant network changes, at any point during the contract year,

the MAO must also follow the requirements at 42 CFR §422.111(e). CMS recommends

that as a best practice, MAOs making significant no-cause network changes should

provide affected enrollees more than the required 30 days advance notice. A longer

notification period is important, not only to address enrollee concerns, furnish enrollees

with needed assistance in selecting new providers, and manage the continuity of care for

those undergoing medical treatment, but also for maintaining enrollee satisfaction. If

enrollees are notified sooner than 30 days prior to a significant provider termination,

then they will be afforded additional time to transition to a new provider.

CMS expects that when an MAO has 60 days advance notice that a contract with a

provider will be terminated (as discussed in section 110.1.2.4 below), the MAO should

notify affected enrollees at least 30 days in advance of the contract termination but

preferably more than 30 days in advance. For those MAOs that do not have the 60 days

advance notice of a contract termination, they must make a good faith effort to notify

affected enrollees as soon as possible and at least 30 days before termination.

As a best practice, MAOs should include the following information in notices to enrollees

in addition to the mandatory identification of the provider(s) being terminated from the

network:

• Names and phone numbers of in-network providers that enrollees may access for

continued care (Note: This information may be supplemented with information for

accessing a current provider directory, including both online and direct mail

options);

• Information regarding how enrollees can request continuation of ongoing medical

treatment or therapies with their current providers; and

• Customer service number(s) where answers to questions about the network changes

will be available.

MAOs should also develop detailed scripts, call center talking points and frequently

asked questions so it can effectively respond to phone inquiries from enrollees and other

stakeholders.

110.1.2.4 – MAO/Provider Notification

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

In accordance with 42 CFR §422.202(d)(4), an MAO and a contracting provider must

provide at least 60 days written notice to each other before terminating the contract

without cause.

110.1.2.5 – Significant Network Change Special Election Period (SEP)

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Pursuant to 42 CFR § 422.62(b)(4), enrollees who meet the exceptional conditions of

being substantially affected by a significant no-cause provider network termination may

be afforded a special election period (SEP).

If CMS determines that an MAO’s network change is significant with substantial enrollee

impact, then a “significant network change SEP” may be warranted. CMS will use a

variety of criteria for making this determination, such as: (1) the number of enrollees

affected; (2) the size of the service area affected; (3) the timing of the termination; (4)

whether adequate and timely notice is provided to enrollees, (5) and any other

information that may be relevant to the particular circumstance(s).

The MAO will be required to notify eligible enrollees of the significant network change

SEP if the SEP is granted by CMS. SEPs will not be granted when MAOs make changes

to their network that are effective on January 1 of the following contract year, as long as

affected enrollees are notified of the changes prior to the AEP.

For more information regarding the significant network change SEP, please see the

Medicare Advantage Enrollment and Disenrollment Guidance at:

https://www.cms.gov/Medicare/Eligibility-and-

Enrollment/MedicareMangCareEligEnrol/index.html.

110.1.3 – Services for Which MA Plans Must Pay Non-contracted

Providers and Suppliers

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

All MAOs must make timely and reasonable payment to, or on behalf of, plan enrollees for

the following services obtained from a provider or supplier that does not contract with the

MAO:

• Ambulance services dispatched through 911 or its local equivalent where other means

of transportation would endanger the beneficiary’s health, as provided in section 20.1

of this chapter;

• Emergency and urgently needed services under the circumstances described in

sections 20.2 through 20.4 of this chapter;

• Maintenance and post-stabilization care services under the circumstances described in

section 20.5 of this chapter;

• Medically necessary dialysis from any qualified provider selected by an enrollee

when the enrollee is temporarily absent from the plan’s service area and cannot

reasonably access the plan’s contracted dialysis providers. An MA plan cannot

require prior authorization or notification for these services. However, the MA plan

may provide medical advice and recommend that the enrollee use a qualified dialysis

provider if the enrollee voluntarily requests such advice because he/she will be out of

area. The MA plan must clearly inform the enrollee that the plan will pay for care

from any qualified dialysis provider the enrollee may independently select.

Furthermore, the cost-sharing for out-of-network medically necessary dialysis may

not exceed the cost-sharing for in-network dialysis;

• Services for which coverage has been denied by the MAO and found (upon appeal

under subpart M of 42 CFR Part 422) to be services the enrollee was entitled to have

furnished, or paid for, by the MAO; and

• Regardless of the MA plan type being offered, arrange for specialty care outside of

the network, but at in-network cost-sharing, in order to provide all Medicare Part A

and Part B benefits. That is, if an enrollee requires a very specialized covered service

that is not provided by the physicians in the network, the plan must arrange for that

service to be provided by a qualified non-contracted provider.

An MA plan (and an MA MSA plan, after the annual deductible has been met) offered by

an MAO generally satisfies its requirements of providing basic benefits with respect to

benefits for services furnished by a non-contracting provider if that MA plan provides

payment in an amount the provider would have been entitled to collect under original

Medicare (see section 170 for guidance on balance billing).

MAOs may negotiate payment amounts with their contracted providers and need not

follow original Medicare payment rates. However, in the absence of a mutual agreement

between the non-contracted provider and the MAO to receive less than the original

Medicare rate, non-contracted providers must accept the original Medicare amount as

payment in full. For further information on payment to non-contracted providers and

suppliers refer to chapter 6, “Relationships with Providers,” of the MMCM. Additional

useful information on payment requirements by MAOs to non-network providers may be

found in the “MA Payment Guide for Out-of-network Payments,” at:

http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/downloads/oon-payments.pdf.

When an enrollee visits an in-network provider, even though that in-network provider

may work with an out of network provider, (e.g., a diagnostic lab that sends specimens to

a central location), then the enrollee is only responsible for in-network cost-sharing.

For further information on an MA plan’s obligation to pay non-contracted providers

when a referral to such a provider was made, see section 160 below.

110.2 – Provider Directories

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

110.2.1 – General

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Pursuant to 42 CFR §422.111(b)(3) MAOs must provide the number, mix, and

distribution (addresses) of providers from whom enrollees may reasonably be expected to

obtain services.

If an MAO chooses to develop a non-model provider directory for either hardcopy or

online provider directories, the directory must contain all information and follow all

instructions within the CMS model provider directory located at:

http://www.cms.gov/Medicare/Health-

Plans/ManagedCareMarketing/MarketngModelsStandardDocumentsandEducationalMat

erial.html. This includes the introductory language and disclaimers.

MAOs can find complete website and electronic media related requirements at section

100 of the Medicare Marketing Guidelines.

MAOs must include information regarding all contracted network providers in

directories at the time of enrollment. Directories must include information about the

number, mix, and distribution of all network providers. MAOs may have separate

directories for each geographic area they serve, (e.g., metropolitan areas, surrounding

county areas), provided that all directories together cover the entire service area.

MAOs may print a separate directory for each sub-network and disseminate that

information to enrollees residing in that particular geographic sub-network. To ensure

that enrollees are fully aware of their overall network provider options, plans that furnish

their enrollees with directories containing a sub-network of plan providers must also

advise enrollees that the complete directory of network providers is available online and

that it will be furnished in hard copy upon request.in plans that have sub-networks.

MAOs also may publish separate primary care physician (PCP) and specialty physician

directories provided both directories are available, online and hard copy, to enrollees at

the time of enrollment and throughout the contract year.

MAOs’ MA-PD plans may combine the model provider and model pharmacy directories

in one document. The guidance in this section, combined with the specific guidance on

pharmacy directories, should be followed when creating a combined provider/pharmacy

directory.

110.2.2 – Provider Directory Updates

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs are expected to update directory information any time they become aware of

changes. All updates to the online provider directories are expected to be completed

within 30 days of receiving information. Updates to hardcopy provider directories must

be completed within 30 days, however, hardcopy directories that include separate

updates via addenda are considered up-to-date.

MAOs should contact their network/contracted providers on a quarterly basis to update

the following information in provider directories:

• Ability to accept new patients;

• Street address;

• Phone number; and

• Any other changes that affect availability to patients.

MAOs should contact providers using a method that is likely to achieve the highest

response rate. It is not sufficient to determine that a group practice is accepting new

patients. Outreach does not apply to entities such as hospitals.

All providers listed in hard copy or online directories must have current contracts to

participate in the MA plan network. Directories provided during the AEP for the

upcoming plan year are expected to fairly represent the network for the upcoming plan

year.

Note: Employer/Union-only Group Waiver Plans (EGWP) may direct enrollees to their

employer for information on the available providers. Employer/Union-only Group

Waiver Plans (EGWP) must comply with the same requirements that are applicable to all

MA and PDP plans regarding the provision of hard copy and online directories.

110.2.3 – Provider Directory Dissemination and Timing

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs must make the provider directory available to all enrollees at the time of

enrollment, and at least annually thereafter by September 30.

MAOs have some flexibility in how they provide access to their provider directories.

MAOs must send all enrollees either the provider directory in hard copy, or a distinct

and separate notice (in hard copy) describing where enrollees can find the provider

directories online and how enrollees can request a hard copy. This notice must be a

stand-alone document (i.e., not bound with other materials) and may be included in the

same mailing envelope as the Annual Notice of Change/Evidence of Coverage

(ANOC/EOC).

To take advantage of this flexibility under §422.11 to provide a notice of on-line

availability instead of providing a hard copy, an MAO must incudes in the notice the

following to ensure that enrollees may access a hard copy:

• If the MAO will not allow requests for a hard copy by email: “If you need help

finding a network provider, please call [customer service phone #] or visit [URL]

to access our online [searchable, if applicable] directory. If you would like a

provider directory mailed to you, you may call the number above, or request one

at the website link provided above.”;

• If the MAO will allow requests for a hard copy by email: “If you need help

finding a network provider, please call [customer service phone #] or visit [URL]

to access our online [searchable, if applicable] directory. If you would like a

provider directory mailed to you, you may call the number above, request one at

the website link provided above, or email [MAO email address].”

110.2.4 – Online Provider Directory Requirements

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs must post a provider directory for all products offered by service areas or by

general geographic area. The provision of accurate provider information and ensuring

adequate access to covered services are essential protections for enrollees. Accurate

provider directories are critical to helping enrollees make educated decisions about their

MA plan choices.

The following formats for the online provider directory are acceptable:

• A searchable “master” provider directory that represents the complete network

for the MAO;

• Individual provider directories by plan product and/or service area (e.g.,

mirroring those that will be printed for the MAO membership); and

• A search engine. If an MAO uses only a search engine on its website, it must meet

all the requirements for the model Directory.

MAOs must also provide the option on their websites for users to request a hard copy

provider directory, as applicable. MAOs are expected to mail the requested hard copy

directory within three (3) business days of the request.

110.2.5 – Provider Directory Disclaimers

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The following is expected to be included in hardcopy and online provider directories if a

directory is for a subset of a service area, Plans must advise members that: “This

directory is for <geographic area>.”

110.2.6 – Provider Directory Submissions to CMS

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs must submit their hardcopy directories to CMS on a yearly basis. All hardcopy

directories must be uploaded into HPMS as a non-marketing material under the XXX

submission code. All hardcopy directories must be uploaded prior to making the

directory available by September 30.

Note that updates and/or addenda pages are not to be uploaded. Because provider

directories are considered non-marketing, MAOs should not include a status after the

material ID. To distinguish the provider directories as non-marketing, the following

material ID should be used: MAO’s contract number, followed by an underscore,

followed by a series of alpha numeric characters chosen at the discretion of the MAO,

followed by an underscore, followed by the letters “NM” (for example,

H1234_ABC123_NM).

110.3 – Health Maintenance Organization (HMO) and HMO Point of

Service (POS) Coverage and Access

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

HMOs restrict the network of providers from which a beneficiary can receive non-

urgent/emergent covered services. HMOs furnish in-network services only.

To ease restrictions on access to out-of-network providers, however, an HMO may offer

a point of service (POS) benefit option. The following rules apply to an HMOPOS:

• Enrollees are allowed the option of receiving specified services outside of the

plan's provider network;

• An HMOPOS may require enrollees to incur increased cost-sharing for POS

services;

• An HMOPOS benefit option may limit out-of-network coverage to a specific

service or services, and may also limit the dollar amount of coverage that will be

provided; and

• The HMOPOS option may be offered as a mandatory supplemental benefit or as

an optional supplemental benefit.

For more information about the POS benefit option for an HMO, see section 30.3 above.

110.4 – Preferred Provider Organization (PPO) Coverage and Access

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

PPOs must furnish all services in-network and out-of-network, but may charge higher

cost-sharing for plan covered services obtained out-of-network. The following rules

apply to PPO coverage outside the service area:

• The out-of-network requirement for PPOs applies to the entire United States and its

territories. For example, a PPO with a service area in Puerto Rico must cover all

plan benefits furnished to its enrollees on the mainland. An MAO wishing to furnish

all plan-covered services outside its service area but only in certain geographic

locations should offer an HMOPOS plan;

• PPO plans must provide reimbursement for all plan-covered medically necessary

services received from non-contracted providers without prior authorization

requirements. However, both enrollees and providers have the right to request a prior

written advance determination of coverage from the plan prior to receiving/providing

services;

• PPO plans offering an optional supplemental benefit must offer the same benefit in-

network and out-of-network;

• PPO plans that cap the dollar value of supplemental benefits must use the same cap

for both in-network and out-of-network benefits; and

• PPO plans are prohibited from establishing prior notification rules under which an

enrollee is charged lower cost-sharing when either the enrollee or the provider

notifies the plan before a service is furnished.

110.5 – Special Rules for RPPOs

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

110.5.1 -- Access through Non-contracted Providers

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Situations may arise where an MA plan cannot establish contracts with providers that

meet Medicare access requirements in portions of an RPPO’s defined service area. In

such cases, RPPOs may meet Medicare access requirements by demonstrating to CMS’

satisfaction that there is adequate access to all plan-covered services through

arrangements other than through contracted provider (42 CFR §422.112(a)(1)(ii)).

Enrollees who receive plan-covered services in non-network areas of an RPPO must be

covered at in-network cost-sharing levels for the enrollee.

110.5.2 – Essential Hospitals

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

42 CFR §422.112(c) describes the requirements for an RPPO to apply to CMS to

designate a non-contracting hospital as an essential hospital. If CMS approves the

application and the hospital continues to meet the requirements at §422.112(c) then the

essential hospital is “deemed” to be a network hospital of the RPPO and normal in-

network inpatient hospital cost-sharing levels (including the catastrophic limit described

in 42 CFR §422.101(d)(2)) apply to all enrollees accessing covered inpatient hospital

services in that hospital.

110.6 – Ensuring Coordination of Care

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The MA plan must ensure continuity of services through arrangements that include, but

are not limited to, the following:

• Implementing policies that specify under what circumstances services are

coordinated and the methods for coordination. The policies should specify whether

the services are coordinated by the enrollee’s primary care provider or in

conjunction or through some other means, e.g. a care management system, a nurse

case manager, clinical prompts, etc.;

• Offering to provide each enrollee with an ongoing source of primary care and

providing a primary care source to each enrollee who accepts the offer;

• Establishing coordination of plan services that integrate services through

arrangements with community and social service programs generally available

through contracted providers or non-contracted providers in the area served by the

MA plan, including nursing home and community-based services;

• Developing and implementing procedures to ensure that the plan and its provider

network have the information required for effective and continuous patient care and

quality review, including procedures to ensure that:

o The plan makes its best effort to conduct an initial health risk assessment (HRA)

of all new enrollees within 90 days of the effective date of enrollment and follows

up on unsuccessful attempts to contact an enrollee. The original Medicare initial

preventive visit (i.e. “Welcome to Medicare” preventive visit), an Annual

Wellness Visit, or a recent previous physical examination in a commercial plan

(to which the MAO has access) would fulfill this obligation;

o The plan makes its best effort to conduct an HRA annually and follows up on

unsuccessful attempts to contact an enrollee.

o The plan makes a good faith effort to annually notify enrollees about the Annual

Wellness Visit;

o Each provider, supplier, and practitioner furnishing services to enrollees

maintains an enrollee health record in accordance with standards established by

CMS and the MAO, taking into account professional standards;

o Enrollees are informed of specific health care needs that require follow up and

receive, as appropriate, information to support and promote their own health;

o Systems are employed to identify and address barriers to enrollee compliance

with prescribed treatments or regimens; and

o There is appropriate, timely, and confidential exchange of clinical information

among provider network components.

110.7 – Access, Gatekeeper and Cost-Sharing by Plan Type

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs may offer a variety of plan types, as shown in Table VII below.

Table VII: Plan Type and Access Attributes for Non-emergent Non-urgent care

Services

Notes:

1) A gatekeeper, when allowed, is typically, but not necessarily, a PCP. A primary

purpose of a gatekeeper is to comply with plan requirements for medically necessary

referrals to in-network specialists. A coordinated care plan may require referral by a

gatekeeper for in-network dialysis services but is prohibited from requiring gatekeeper

referral for out-of-network dialysis services.

2) Although an RPPO must contract with a network, it may, upon obtaining a waiver

from CMS, only contract with a network in part of its service area (42 CFR

§422.112(a)(1)(ii)).

120 – Coordination of Medicare Benefits with Employer/Union Group

Health Plans and Medicaid

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

If an MAO contracts with an employer, labor organization, or the trustees of a fund

established by one or more employers or labor organizations that cover enrollees in an

MA plan, or contracts with a State Medicaid agency to provide Medicaid benefits to

individuals who are eligible for both Medicare and Medicaid, and who are enrolled in an

MA plan, the enrollees must be provided the same benefits as all other enrollees in the

MA plan, with the employer, labor organization, fund trustees, or Medicaid benefits

supplementing the MA plan benefits.

Plan Type

Is a

gatekeeper

allowed?

Is a network

required?

Must benefits

be provided In-

network and

OON?

May Cost-

sharing

requirements

differ In-

network/OON

HMO

Optional

Must contract

Must provide

In-network only

Not applicable

HMOPOS

Optional

Must contract

Must provide

in-network;

must provide

specific OON

May have higher

cost-sharing

OON

PPO, RPPO

Optional, In-

network;

Prohibited Out-

of-network

(OON)

Must contract

Must provide

both in-

network/OON

May have higher

cost-sharing

OON

MSA and

PFFS

Prohibited

May use full,

partial, or non-

network model

Must provide

both in-

network/OON

May have higher

cost-sharing

OON

120.1 – General Rule

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

An MAO may contract with employers, unions, or State Medicaid Agencies to pay for

benefits that complement those that an employee or retiree receives under an MA plan

(see 42 CFR §422.106(a)(2)). Some examples of complementary benefits include the

following:

• The employer, union or State Medicaid Agency pays, or is financially responsible, for

some, or all, of the MA plan’s basic premiums, supplemental premiums, or cost-

sharing;

• The employer, union, or State Medicaid Agency provides other employer-sponsored

(or state-sponsored) services that may require additional premium and cost-sharing;

• The employer, union or State Medicaid Agency purchases a non-Part D drug benefit

from the MAO.

These complementary benefits may not be classified as MA benefits and therefore are not

regulated or reviewed by CMS. However, the MAO must comply with all state

regulations governing such benefits. Refer to chapter 9, “Employer/Union Group Health

Plans,” of the MMCM, for further information.

120.2 – Requirements, Rights, and Beneficiary Protections

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

All requirements, rights, and protections that apply to the MA program also apply to all

MA plan benefits – that is, the basic, mandatory and optional supplemental benefits

discussed in this chapter. By contrast, the employer, labor organization, fund trustees or

State Medicaid benefits that complement the MA plan benefits are not considered MA

benefits and are therefore beyond the scope of MA regulations. Marketing materials

associated with the complementary benefits are also not subject to CMS approval. (See

the Medicare Marketing Guidelines for further discussion at:

https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/2016-

Medicare-Marketing-Guidelines-Updated.pdf.)

Medicaid benefits provided through a contract with an MAO to provide coverage for

individuals eligible for both Medicare and Medicaid and who are enrolled in an MA plan

are subject to Medicaid rules and regulations, including CMS review where applicable.

120.3 – Employer/Union Plans

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

For more details on employer/union coverage see chapter 9 of the MMCM,

“Employer/Union-Sponsored Group Health Plans.”

130 – Medicare Secondary Payer (MSP) Procedures

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

130.1 – Basic Rule

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

CMS does not pay for services to the extent that there is a third party that is required to

be the primary payer. The principles on cost-sharing that are discussed below may not

apply in circumstances where CMS has granted an employer group waiver. (See chapter

9 of the MMCM “Employer/Union Sponsored Group Health Plans,” for further

discussion.)

This section only applies to collections related to Part C benefits. Special rules apply to

the collection of cost-sharing related to Part D benefits offered in an MA-PD plan. These

Part D rules are found in chapter 14, “Coordination of Benefits,” of the Prescription Drug

Benefit Manual, publication 100-18, located at: http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/Pub100_18.pdf.

130.2 – Responsibilities of the MAO

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

The MAO must, for each MA plan:

• Identify payers that are primary to Medicare;

• Identify the amounts payable by those payers; and

• Coordinate its benefits to Medicare enrollees with the benefits of the primary payers.

130.3 – Medicare Benefits Secondary to Group Health Plans (GHPs)

and Large Group Health Plans (LGHPs) and in Settlements

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Secondary payer status can arise from legal settlements, as well as other insurance plans.

MAOs should refer to the Medicare Secondary Payer Manual, publication 100-05, located

at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-

Manuals-IOMs-Items/CMS019017.html for additional information.

In the case of an enrollee’s coverage by another insurance plan, secondary payer status

may, in certain circumstances, depend on:

• Whether the enrollee entitlement to Medicare is due to age, ESRD, or disability;

• Who is the primary beneficiary of the other insurance plan;

• Whether the primary beneficiary is covered by the employer Group Health Plan

(GHP) as an active or former employee; and/or

• The size (number of employees) of the sponsoring employer group.

Specifically, but not exclusively, an MAO is the secondary payer in the following

situations:

• When the MA plan has an MA enrollee who is 65 years or older, and the enrollee:

o Is covered by a GHP because of either:

 The enrollee’s current employment; or

 Current employment of a spouse of any age; and

o The employer that sponsors or contributes to the GHP employs 20 or more

employees.

• When the MA plan has an MA enrollee who is disabled, and the enrollee:

o Is covered by a Large Group Health Plan (LGHP) because of either:

 Current employment; or

 A family member’s current employment; and

o The employer that sponsors or contributes to the LGHP plan employs 100

or more employees; or

• During the first 30 months of eligibility or entitlement to Medicare for an MA

enrollee whose entitlement to Medicare is solely on the basis of ESRD and group

health plan coverage (including a retirement plan). This provision applies regardless

of the number of employees and the enrollee’s employment status.

Secondary payer status may also be triggered due to legal settlements. In this case, the

MAO is the secondary payer for an MA enrollee when:

• The proceeds from the enrollee’s workers’ compensation settlement are available; and

• The proceeds from the enrollee’s no-fault or liability settlement is available.

Medicare does not pay at all for services covered by a primary GHP. In the case of the

presence of workers compensation, no-fault and liability insurance (including self-

insurance), Medicare makes conditional payments if the other insurance does not pay

promptly. These conditional payments are subject to recovery when and if the other

insurance does make payment.

MAOs may not withhold primary payment unless there is a reasonable expectation that

another insurer will actually promptly pay primary to Medicare. Thus for example, if an

MA enrollee did not have auto insurance, the MAO cannot withhold primary payment on

the grounds that the enrollee should have had this insurance because it is a state

requirement.

130.4 – Collecting From Other Entities

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The MAO may bill, or authorize a provider to bill, other individuals or entities for

covered Medicare services for which Medicare is not the primary payer, as specified in

sections 130.5 and 130.6 below.

130.5 – Collecting From Other Insurers or the Enrollee

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

If an MA enrollee receives plan-covered services that are also covered under an employer

group health plan, state or Federal workers’ compensation, no-fault insurance, or any

liability insurance policy or plan, including a self-insured plan, the MAO may bill, or

authorize a provider to bill any of the following:

• The insurance carrier, the employer/union, or any other entity that is liable for

payment for the services under section 1862(b) of the Act; and

• The enrollee, to the extent that s/he has been paid by the insurance carrier,

employer/union, or entity for covered medical expenses.

130.6 – Collecting From Group Health Plans (GHPs) and Large Groups

Health Plans (LGHPs)

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

If an MAO is the secondary payer to a GHP/LGHP and, for a given service, the cost-

sharing required by the GHP/LGHP is greater than the cost-sharing required by the MAO

then:

• The enrollee must pay the MAO’s plan cost-sharing; and

• The MAO pays the GHP/LGHP the difference between that higher cost-sharing and

the MAO plan cost-sharing (see 42 CFR § 422.504(g), which obligates the MAO,

even if it is a secondary payer, to protect the enrollee from paying more than plan

cost-sharing).

Example: If the GHP (the primary payer) has a co-payment of $20 and the MA plan has a

co-payment of $10 for a plan-covered service that the enrollee properly received

(following all plan requirements), the enrollee may not be held liable for paying more

than the MA plan’s co-payment of $10. The MAO must hold the enrollee harmless for

any amount in excess of the MA plan co-payment of $10.

130.7 – Medicare as Secondary Payer (MSP) Rules and State Laws

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Consistent with Federal preemption of state law, addressed at 42 CFR § 422.402 and 42

CFR § 422.108, a state cannot take away an MAO's right under Federal law and the MSP

regulations to bill, or to authorize providers and suppliers to bill, for services for which

Medicare is not the primary payer. The MAO may exercise the same rights to recover

from a primary plan, entity, or individual that the Secretary exercises under the MSP

regulations as they apply to MA Plans.

(See chapter 8 of the MMCM, “Payments to Medicare Advantage Organizations” for

further discussion of Medicare Secondary Payer and Coordination of Benefits.)

140 – Service Area

(Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15)

140.1 – Service Area Defined

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

A service area is a geographical area approved by CMS within which an MA eligible

individual may enroll in a particular MA plan offered by an MAO. A local MA plan’s

service area does not need to be contiguous. A regional PPO’s service area must be the

entire MA region. The basic requirement of service area is that each MA plan offered by

an MAO must be offered to all enrollees in an MA plan’s service area and must provide a

uniform benefit package and uniform cost-sharing arrangements.

The designation of an MA plan’s service area affects the following five items:

• Payment Rate: The service area designation determines the benchmark applicable to

the plan, and therefore, CMS’ payment rate to the MAO for the MA plan;

• Required Benefits: The designation affects which benefits will be provided under the

MA plan, because benefits and premiums must be uniform for all Medicare

beneficiaries residing in the plan’s service area;

• Eligibility: The designation determines which Medicare beneficiaries are able to elect

the plan. With the exception of SNPs, which can limit enrollment based upon

statutory and regulatory parameters, MAOs are obligated to enroll any MA eligible

resident in the service area who elects the plan during an applicable enrollment period

(provided an approved capacity limit has not yet been reached (see chapter 2 of the

MMCM, “Enrollment and Disenrollment”) located at:

http://www.cms.gov/Medicare/Eligibility-and-

Enrollment/MedicareMangCareEligEnrol/index.html?redirect=/MedicareMangCareEl

igEnrol/);

• Access Requirements: For coordinated care plans, the designation identifies the

geographical area in which the plan’s covered services must be “available and

accessible;” and

• Urgently Needed Services: For coordinated care plans, the designation defines the

boundaries beyond which the MAO must cover urgently needed services.

140.2 – Factors That Influence Service Area Approvals

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

In deciding whether to approve an MA plan’s service area, CMS considers whether:

• Each MA plan (except for Employer/Union-Only plans; see chapter 9 of the

MMCM, “Employer/Union-Sponsored Group Plans”) will be made available to all MA

eligible individuals within the plan’s service area;

• The plan will offer a uniform premium, benefit package and cost-sharing

arrangement to all beneficiaries in the service area, or segment of a service area;

• The service area meets the “county integrity rule” that a service area generally

consists of a full county or counties as described in § 422.2 (definition of service area)

and below in section 140.3; and

• For coordinated care plans, the contracting provider network meets CMS access and

availability standards for the service area, as explained in section 110 of this chapter,

even if some of the contracting providers are physically located outside of the service

area.

140.3 – Partial County Service Areas

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

This subsection only applies to local MA plans.

CMS will generally approve only full counties in a service area, in order to prevent the

establishment of boundaries that could “game” the county-wide MA payment system by

excluding an area of the county where beneficiaries with expected higher health care

utilization might reside. However, the counties do not need to be contiguous, and under

limited circumstances described below, CMS may approve the inclusion of “partial”

counties in a service area.

CMS will consider approving a service area that includes a partial county, if it determines

that the inclusion of a partial county is: (1) necessary, (2) non-discriminatory, and (3) in

the best interest of the beneficiaries. All three of these factors must be present in order

for CMS to approve an exception to the county integrity rule. CMS may also consider the

extent to which the proposed service area mirrors the service area of existing commercial

health care plans or MA plans offered by the MAO and whether there are other MA plans

serving the entire county.

140.3.1 – Necessity

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

For CMS to determine that a partial county is necessary, an MAO must be able to

demonstrate that the MAO cannot establish a provider network to make health care

services available and accessible to beneficiaries residing in the portion of the county to

be excluded from the service area.

The following examples illustrate how an HMO or other type of local MA plan may have

a health care network that is limited to one part of a county and cannot be extended to

encompass an entire county.

Example 1: A section of a county has an insufficient number of providers (or insufficient

capacity among existing providers) to ensure access and availability to covered services.

• Example 2: Geographic features, such as mountains, water barriers, and exceptionally

large counties create situations where the local pattern of care in the county justifies

less than a complete county because covered services are not available and accessible

throughout the entire county.

140.3.2 – Non-Discriminatory

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

For CMS to determine if a partial county is non-discriminatory, an MAO must be able to

demonstrate the following:

• The anticipated enrollee health care cost of the portion of the county it proposes to

serve is similar to the area of the county that will be excluded from the service area.

For example, if the MAO is requesting a service area reduction (creating a new partial

county) the MAO can demonstrate its anticipated cost of care (in the partial county

area) by using data from the previous year of MA contracting comparing the health

care costs of its enrollees in the excluded area to those in the area of the county it

proposes to serve; and

• The racial and economic composition of the population in the portion of the county it

wants to serve is comparable to the excluded portion of the county. For example, the

MAO can use U.S. census data to show the demographic make-up of the included

portion of the county as compared to the excluded portion.

Note that the existence of other MA plans operating in the entire county may provide

evidence that approving a partial county service area application would be

discriminatory.

140.3.3 -Best Interests of Beneficiaries

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

In order for CMS to determine whether a partial county is in the best interest of

beneficiaries, an MAO must provide reasonable documentation to support their request.

As previously noted, CMS will generally only approve partial counties when it is not

possible for an MAO to serve an entire county.

An MAO may not create a service area that excludes portions of a county because it

believes enrollees with anticipated higher health care costs or needs reside in the portions

of the county to be excluded from the service area.

150 – Benefits during Disasters and Catastrophic Events

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The Secretary of Health and Human Services (the Secretary) has the right to exercise his

or her waiver authority under section 1135 of the Social Security Act if, in addition to a

Presidential declaration of a disaster or emergency under the Stafford Act or National

Emergencies Act, the Secretary declares a public health emergency under section 319 of

the Public Health Service Act. If an 1135 waiver is issued, CMS will identify all plan

requirements and responsibilities. Detailed guidance and requirements for MA plans

under the section 1135 waiver, including timeframes associated with those requirements

and responsibilities, will be posted on the Department of Health and Human Services

website, (http://www.hhs.gov/) and the CMS website (http://www.cms.hhs.gov/). MAOs

are expected to check these sites frequently during such disasters and emergencies.

Under the Secretary’s section 1135 waiver authority, CMS may authorize DME and A/B

MACs to pay for Part C-covered services furnished to enrollees and seek reimbursement

from MAOs for those health care services, retrospectively.

In the event of a Presidential emergency declaration, a Presidential (major) disaster

declaration, a declaration of emergency or disaster by a Governor, or an announcement

of a public health emergency by the Secretary of Health and Human Services, but absent,

or prior to the issuance of, a section 1135 waiver by the Secretary, MAOs must:

• Allow Part A and Part B and supplemental Part C plan benefits to be furnished at

specified non-contracted facilities (note that Part A and Part B benefits must, per 42

CFR §422.204(b)(3), be furnished at Medicare certified facilities);

• Waive in full, requirements for gatekeeper referrals where applicable;

• Temporarily reduce plan-approved out-of-network cost-sharing to in-network cost-

sharing amounts; and

• Waive the 30-day notification requirement to enrollees as long as all the changes

(such as reduction of cost-sharing and waiving authorization) benefit the enrollee.

Typically, the source that declared the disaster will clarify when the disaster or

emergency is over. If, however, the disaster or emergency timeframe has not been closed

30 days from the initial declaration, and if CMS has not indicated an end date to the

disaster or emergency, plans should resume normal operations 30 days from the initial

declaration. MAOs not able to resume normal operations after 30 days should notify

CMS.

MAOs must disclose their policies about providing benefits during disasters on their plan

websites.

If the President has declared a major disaster or the Secretary has declared a public

health emergency, MAOs must follow the guidance in chapter 5 of the Prescription Drug

Benefit Manual, regarding refills of Part D medications. The Prescription Drug Benefit

Manual may be found at: http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/Pub100_18.pdf.

160 – Beneficiary Protections Related to Plan-Directed Care

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Organization Determinations: An enrollee, or a provider acting on behalf of the enrollee,

always has the right to request a pre-service organization determination if there is a

question as to whether an item or service will be covered by the plan. If the plan denies

an enrollee’s (or his/her treating provider’s) request for coverage as part of the

organization determination process, the plan must provide the enrollee (and provider, as

appropriate) with the standardized denial notice (Notice of Denial of Medical Coverage

(or Payment)/CMS-10003). For the requirements related to organization determinations

and issuance of the standardized denial notice (CMS-10003), see chapter 13 of the

MMCM located at: https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/mc86c13.pdf.

Limitations on Enrollee Liability: CMS considers a contracted provider an agent of the

MAO offering the plan. As stated in the preamble to the January 28, 2005 final rule

(CMS-4069-F):

“MA organizations have a responsibility to ensure that contracting physicians and

providers know whether specific items and services are covered in the MA plan in which

their patients are enrolled. If a network physician furnishes a service or directs an MA

beneficiary to another provider to receive a plan-covered service without following the

plan’s internal procedures (such as obtaining the appropriate plan pre-authorization),

then the beneficiary should not be penalized to the extent the physician did not follow

plan rules.”

Consequently, when a contracted provider furnishes a service or refers an enrollee for a

service that an enrollee reasonably believes is a plan-covered service, the enrollee

cannot be financially liable for more than the applicable cost-sharing for that service. If

a contracted provider believes an item or service may not be covered for an enrollee, or

could be covered only under specific conditions, the appropriate process is for the

enrollee or provider to request a pre-service organization determination from the plan.

If a contracted provider refers an enrollee to a non-contracted provider for a service that

is covered by the plan upon referral, the enrollee is financially liable only for the

applicable cost-sharing for that service. Contracted providers are expected to coordinate

care or work with plans prior to referring an enrollee to a non-contracted provider to

ensure, to the extent possible, that enrollees are receiving medically necessary services

covered by their plan. Furthermore, plans are expected to work with their contracted

providers to ensure that clear processes are in place and providers are educated about

those processes, including appropriate documentation, to substantiate that a referral has

been made.

If a service is never covered by the plan and the plan’s Evidence of Coverage (EOC)

provided to the enrollee is clear that the service or item is never covered, the plan is not

required to hold the enrollee harmless from the full cost of the service or item. For a

service or item that is typically not covered, but could be covered under specific

conditions (e.g., dental care that is necessary to treat an illness or injury), the EOC, in

and of itself, is not adequate notice of non-coverage for purposes of determining enrollee

liability. In such instances, the appropriate process is for the enrollee, or the provider

acting on behalf of the enrollee, to request a pre-service organization determination. If

the plan denies the service, the plan must issue the standardized denial notice with

appeal rights. The enrollee has the right to appeal any denial of a service or item. Plans

also must educate their contracted providers about the limits of plan coverage and the

need to correctly advise enrollees when providing referrals for covered services. This

will prevent confusion related to plan coverage and enrollee financial liability as well as

ensure coordination of the care furnished.

When the provider, or the plan acting on behalf of the provider, can show that an

enrollee was notified (via a clear exclusion in the EOC or the standardized denial notice)

prior to receipt of the item or service that the item or service is not covered by the plan or

that coverage is available only if the enrollee is referred for the service by a contracted

provider but the enrollee nonetheless receives that item or service in the absence of a

referral, the regulation at §422.105(a) does not require the MA plan to hold the enrollee

harmless from the full cost of the service or item charged by the provider.

170 – Balance Billing

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The guidance in this section applies to HMOs (Health Maintenance Organizations),

HMOPOS (HMO Point of Service), PPOs (Preferred Provider Organizations), and

RPPOs (Regional PPOs).

When enrollees obtain plan-covered services in an HMO, PPO, or RPPO, they may not

be charged or held liable for more than plan-allowed cost-sharing. Providers who are

permitted to ‘balance bill’ must obtain the amount in excess of the enrollee’s cost-

sharing (the balance) for services, directly from the MAO and not from the enrollee.

170.1 – Definitions

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Note: Under original Medicare rules, a Medicare participating provider (hereinafter

referred to as a participating provider) is a provider that signs an agreement with

Medicare to always accept assignment. The MACs post lists of Medicare participating

providers. Participating providers may never balance bill because they have agreed to

always accept the Medicare allowed amount as payment in full. An original Medicare

non-participating provider (hereinafter referred to as a non-participating, or non-par,

provider) may accept assignment on a case-by-case basis and indicates this by checking

affirmatively in field 27 on the CMS 5010 claims form. In these instances, no balance

billing of enrollees by the provider is permitted.

170.2 – Balance Billing by Provider Type

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The rules governing balance billing as well as the rules governing the MA payment of

MA-plan contracting providers, non-contracting providers and original Medicare

participating and non-participating providers are listed below by type of provider.

• Contracted provider: There is no balance billing paid by either the plan or the

enrollee.

• Non-contracting, original Medicare, participating provider: There is no balance

billing paid by either the plan or the enrollee.

• Non-contracting, non-(Medicare)-participating provider: The MAO must pay the

non-contracting, non-participating (non-par) provider the difference between the

enrollee’s cost-sharing and the original Medicare limiting charge, which is the

maximum amount that original Medicare requires an MAO to reimburse a provider.

The enrollee only pays plan-allowed cost-sharing, which equals:

o The copay amount, if the MAO uses a copay for its cost-sharing; or

o The coinsurance percentage multiplied by the limiting charge, if the MAO uses a

coinsurance method for its cost-sharing.

• MA-plan, non-contracting, non-participating DME supplier: The MAO must pay the

non-contracting non-participating (non-par) DME supplier the difference between

the enrollee’s cost-sharing and the DME supplier’s bill; the enrollee only pays plan-

allowed cost-sharing, which equals:

o The copay amount, if the MAO uses a copay for its cost-sharing; or

o The coinsurance percentage multiplied by the total provider bill, if the MAO uses

a coinsurance method for its cost-sharing. Note that the total provider bill may

include permitted balance billing.

For information about payment to providers that have “opted-out” of Medicare, refer to

chapter 6 of the MMCM, “Relationships with Providers” at:

http://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/mc86c06.pdf

Additional useful information on payment requirements by MAOs to non-network

providers may be found in “MA Payment Guide for Out-of-network Payments,” at:

http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/downloads/oon-payments.pdf.

MA plans must clearly communicate to enrollees through the Evidence of Coverage

(EOC) and Summary of Benefits (SB) their cost-sharing obligations as well as the

enrollees’ lack of obligation to pay more than the allowed plan cost-sharing as described

above.

180 – Information on Advance Directives

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

180.1 – Definition

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Advance directives are written instructions, such as living wills or durable powers of

attorney for health care, recognized under state law and signed by a patient, that explain

the patient’s wishes concerning the provision of health care if the patient becomes

incapacitated and is unable to make those wishes known.

180.2 – Basic Rule

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

Pursuant to 42 CFR §422.128, the MAO must:

• Maintain written policies and procedures that meet the requirements for advance

directives that are set forth in this section; and

• Provide to its adult enrollees, at the time of initial enrollment, written information on

their rights under the law of the state in which the MAO furnishes services to make

decisions concerning their medical care, including the right to accept or refuse

medical or surgical treatment, and the right to formulate advance directives.

The MAO is permitted to contract with other entities to furnish information concerning

advance directive requirements. However, the MAO remains legally responsible for

ensuring that the requirements of this section are met. Further details concerning the

written information that must be given to enrollees as well as other obligations are

outlined below in section 180.4.

180.3 – State Law Primary

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The MA program’s advance directive requirements are guidelines that refer to state law,

whether statutory or recognized by the courts of the state. Therefore, MAOs must comply

with the advance directive requirements of the states in which they provide services. CMS

cannot provide detailed guidelines as to what constitutes best efforts in each state.

Medicare regulations give MAOs and states a great deal of flexibility, and CMS will

work with the MAO (and the state, if needed) to ensure that advance directive

requirements conform to Federal law. Changes in state law must be reflected in the

information MAOs provide their enrollees as soon as possible, but no later than 90 days

after the effective date of the state law or the date of the court order.

180.4 – Content of Enrollee Information and Other MA Obligations

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The written information provided to enrollees must, at a minimum, include a description

of the MAO’s written policies on advance directives, including an explanation of the

following:

• That the MAO cannot refuse care or otherwise discriminate against an individual

based on whether or not the individual has executed an advance directive;

• The right to file a complaint about an MAO’s noncompliance with advance directive

requirements, and where to file the complaint;

• That the plan must document in a prominent part of the individual’s current medical

record whether or not the individual has executed an advance directive;

• That the MAO is required to comply with state law (See section 180.3 for details);

• That the MAO must educate its staff about its policies and procedures for advance

directives; and

• That the MAO must provide for community education regarding advance directives.

If the MAO cannot implement an advance directive as a matter of conscience, it must

issue a clear and precise written statement of this limitation. The statement must include

information that:

• Explains the differences between institution-wide objections based on conscience and

those that may be raised by individual physicians;

• Identifies the state legal authority permitting such objection; and

• Describes the range of medical conditions or procedures affected by the conscience

objection.

180.5 – Incapacitated Enrollees

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

If an enrollee is incapacitated at the time of initial enrollment and is unable to receive

information due to an incapacitating condition, the MAO may give advance directive

information to the enrollee’s family or surrogate. The MAO is not relieved of its

obligation to provide this information to the enrollee once s/he is no longer incapacitated

or unable to receive such information. Follow-up procedures must be in place to ensure

that the information is given directly to the individual at the appropriate time.

180.6 – Community Education Requirements

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The MAO must provide for community education regarding advance directives either

directly or in concert with other providers or entities. Separate community education

materials may be developed and used at the discretion of the MAO for separate parts of

the community. Although the same written materials are not required for all settings, the

material should define what constitutes an advance directive, emphasizing that an

advance directive is designed to enhance an incapacitated individual’s control over

medical treatment, and describe applicable state law concerning advance directives. An

MAO must be able to document its community education efforts.

180.7 – MAO Rights

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The MAO is not required to provide care that conflicts with an advance directive. The

MAO is not required to implement an advance directive if, as a matter of conscience, the

MAO cannot implement an advance directive and state law allows any health care

provider or any agent of the provider to conscientiously object.

180.8 – Anti-discrimination Rights

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

An MAO may not condition the provision of care or otherwise discriminate against an

individual based on whether or not the individual has executed an advance directive.

Furthermore, the MAO must inform individuals that complaints concerning

noncompliance with the advance directive requirements may be filed with the State

Survey and Certification Agency.

190 – Part C Explanation of Benefits (EOB)

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

The Part C EOB is an ad hoc enrollee communication that provides MA enrollees with

clear and timely information about their medical claims to support informed decisions

about their healthcare options. MAOs are required to issue EOBs that include the

information reflected in the CMS-developed templates. For additional information,

please see the final templates and instructions at: http://www.cms.gov/Medicare/Health-

Plans/ManagedCareMarketing/MarketngModelsStandardDocumentsandEducationalMat

erial.html.

200 – Educating and Enrolling Members in Medicaid and Medicare

Savings Programs

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

200.1 – Defining Guidance

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

This guidance pertains to Medicare contracting organizations (and entities with which

they contract) that educate their current Medicare (including Part C, Part D and Cost

plan) enrollees about Medicaid and/or Medicare Savings Programs, assist enrollees with

determining potential eligibility for those programs and helping enrollees actually enroll

in those programs. This guidance also pertains to organizations that help enrollees

maintain their eligibility and enrollment in these programs.

200.2 – Relationship to D-SNP Eligibility/Enrollment

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

This guidance on educating and enrolling enrollees in financial assistance programs in

no way affects or relates to an MAO’s responsibility for determining an enrollee’s, or

potential enrollee’s, eligibility to enroll in the MAO’s Dual-Eligible Special Needs Plan

(D-SNP). Refer to the MMCM chapter 2 for guidance on D-SNP eligibility and

enrollment.

200.3 – Relationship to Dual Eligible Demonstration Programs

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs should be aware of how an enrollee’s eligibility for Medicaid might affect their

enrollees’ continued plan enrollment in those states or counties where Financial

Alignment Initiative demonstrations with passive enrollment exist. More information,

including state-specific names for the Financial Alignment Initiative, is available at

https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-

Coordination/Medicare-Medicaid-Coordination-

Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoord

ination.html.

200.4 – Scope of Financial Assistance Programs

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs that provide education and/or enrollment assistance to enrollees must provide this

across the full scope of Medicaid and Medicare Savings Programs:

• Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only)

• QMBs with full Medicaid (QMB Plus)

• Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid

(SLMB Only)

• SLMBs with full Medicaid (SLMB Plus)

• Qualified Disabled and Working Individuals (QDWIs)

• Qualifying Individuals (QIs)

• Medicaid-Only Dual Eligibles (Non QMB, SLMB, QDWI, QI)

200.5 – Targeting Membership

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

MAOs may conduct education and enrollment assistance for only a portion of its plan

membership. Selection of the focus population may be based upon demographic data or

on a specific geographic area. However, the MAO must provide outreach to all enrollees

within those pre-identified population segments. Additionally, if the MAO receives an

inquiry from a plan enrollee not previously identified in the targeted group, it must

provide assistance to that enrollee as if he or she had been included in the initial group.

200.6 – Required Elements of Education/Enrollment Assistance Programs

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

In its education and enrollment assistance programs, the MAO must include the

following elements in its written and oral communications with plan enrollees:

• Clarification that the enrollee may voluntarily offer information, including financial

information, for assistance with enrolling in or maintaining enrollment in state

financial assistance, but that the enrollee is not obligated to provide this information.

• Clarification that the enrollee’s failure to provide information will in no way

adversely affect the enrollee’s membership in his or her health plan.

• Clarification that the Medicare Savings Programs are part of either the “State

Medicaid program” or “State medical assistance programs.”

• Clarification that the plan sponsor is only providing an initial eligibility screening

and that only the appropriate State Agency can make a final eligibility determination.

• Guidance to an enrollee on how to proceed with the application process even if the

MAO’s screening process indicates that the enrollee is probably not eligible for

assistance under any of the dual eligibility programs.

• Alternate sources of information, including the telephone number for enrollees to call

the SHIP and the appropriate State Agency. Outreach materials may also include the

1-800-MEDICARE (1-800-633-4227) number and the (1-800-486-2048) TTY number.

The MAO must coordinate its education and enrollment efforts with the appropriate State

Medicaid Agency and local SHIP offices so that these entities are aware of the MAO’s

efforts.

MAOs may provide assistance to the enrollee in completing applications for financial

assistance including submitting the paperwork to the appropriate State office.

200.7 – CMS Oversight

(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)

At any time, CMS may request, and the MAO must provide, any information related to the

education and enrollment assistance program. This includes, but is not limited to, the

information listed below. Should any of that information be unavailable or show lack of

compliance with the required elements of the program, CMS may take compliance

actions against the MAO.

• A detailed description of each step in the outreach process and the entity responsible

for each step. (CMS recommends a flow chart showing the result of each action.);

• A timeline showing the proposed dates of outreach activities, the number of enrollees

involved in each activity, and the service area, (e.g., county), included in the

activities;

• Executed contracts with all external entities involved in the outreach process. This

includes contracts with any subcontractors taking part in the activities;

• Supporting documentation from the appropriate state agency providing specific state

income requirements for each savings program level, and names and contacts within

the appropriate state agency/agencies;

• Internal training programs the MAO is using to educate staff involved in education

and enrollment assistance. An internal plan for protecting the confidentiality of the

enrollee’s financial or other personal information gathered in the outreach process;

• Outreach letters and other materials, (e.g., brochures, Authorization to Represent

form), going to plan enrollees; and

Telephone scripts or other outreach assistance scripts that will guide representatives in

answering enrollees’ questions or discussing the assistance available to them. Such

scripts must include a privacy statement clarifying that the enrollee is not required to

provide any information to the representative and that the information provided will in

no way affect the enrollee’s membership in the plan.

Transmittals Issued for this Chapter

Rev #

Issue Date

Subject

Impl Date

CR#

R116MCM

01/16/2015

Chapter 4, Quality Improvement Program

01/01/2015

N/A

R115MCM

08/23/2013

Chapter 4,”Benefits and Beneficiary

Protections”

08/23/2013

N/A

R107MCM

06/22/2012

Chapter 4,”Benefits and Beneficiary

Protections”

06/22/2012

N/A

R97MCM

05/20/2011

Chapter 4,”Benefits and Beneficiary

Protections”

05/20/2011

N/A

R94MCM

12/03/2010

Chapter 4,”Benefits and Beneficiary

Protections”

12/03/2010

N/A

R92MCM

12/18/2009

Chapter 4,”Benefits and Beneficiary

Protections”

12/18/2009

N/A

R87MCM

06/08/2007

Update of Chapter 4,”Benefits and

Beneficiary Protections”

06/08/2007

N/A

R72MCM

09/30/2005

Changes in Manual Instructions for Benefits

and Beneficiary Protections

N/A

R61MCM

09/03/2003

Emergency and Urgently Needed Services

N/A

R49MCM

04/09/2004

Access and Availability Rules for

Coordinated Care Plans and Continuity of

Care

N/A

R43MCM

01/09/2004

Sources for Obtaining Information

N/A

R36MCM

10/31/2003

Miscellaneous Changes

N/A

R23MCM

06/06/2003

Initial Issuance of Chapter

N/A