[Code of Federal Regulations]
[Title 42, Volume 2]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR422.105]

[Page 849-850]
 
                         TITLE 42--PUBLIC HEALTH
 
                             HUMAN SERVICES
 
PART 422--MEDICARE+CHOICE PROGRAM--Table of Contents
 
             Subpart C--Benefits and Beneficiary Protections
 
Sec. 422.105  Special rules for point of service option.

    (a) General rule. A POS benefit is an option that an M+C 
organization may offer in an M+C coordinated care plan or network M+C 
MSA plan to provide enrollees with additional choice in obtaining 
specified health care services. The organization may offer a POS option-
-
    (1) Under a coordinated care plan only as an additional benefit as 
described in Sec. 422.312;
    (2) Under a coordinated care plan only as a mandatory supplemental 
benefit as described in Sec. 422.102(a); or
    (3) Under a coordinated care plan or network MSA plan as an optional 
supplemental benefit as described in Sec. 422.102(b).
    (b) Approval required. An M+C organization may not implement a POS 
benefit until it has been approved by CMS.
    (c) Ensuring availability and continuity of care. An M+C network 
plan that includes a POS benefit must continue to provide all benefits 
and ensure access as required under this subpart.
    (d) Enrollee information and disclosure. The disclosure requirements 
specified in Sec. 422.111 apply in addition to the following 
requirements:
    (1) Written rules. M+C organizations must maintain written rules on 
how to obtain health benefits through the POS benefit.
    (2) Evidence of coverage document. The M+C organization must provide 
to beneficiaries enrolling in a plan with a POS benefit an ``evidence of 
coverage'' document, or otherwise provide written documentation, that 
specifies all costs and possible financial risks to the enrollee, 
including--
    (i) Any premiums and cost-sharing for which the enrollee is 
responsible;
    (ii) Annual limits on benefits and on out-of-pocket expenditures;
    (iii) Potential financial responsibility for services for which the 
plan denies payment because they were not covered under the POS benefit, 
or exceeded the dollar limit for the benefit; and
    (iv) The annual maximum out-of-pocket expense an enrollee could 
incur.

[[Page 850]]

    (e) Prompt payment. Health benefits payable under the POS benefit 
are subject to the prompt payment requirements in Sec. 422.520.
    (f) POS-related data. An M+C organization that offers a POS benefit 
through an M+C plan must report enrollee utilization data at the plan 
level by both plan contracting providers (in-network) and by non-
contracting providers (out-of-network) including enrollee use of the POS 
benefit, in the form and manner prescribed by CMS.

[63 FR 35077, June 26, 1998, as amended at 65 FR 40320, June 29, 2000]