[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: 42CFR422.109]

[Page 851-852]
 
                         TITLE 42--PUBLIC HEALTH
 
                             HUMAN SERVICES
 
PART 422--MEDICARE+CHOICE PROGRAM--Table of Contents
 
             Subpart C--Benefits and Beneficiary Protections
 
Sec. 422.109  Effect of national coverage determinations (NCDs).

    (a) If CMS determines and announces that an NCD meets the criteria 
for ``significant cost'' described in paragraph (c) of this section, an 
M+C organization is not required to assume risk for the costs of that 
service until the contract year for which the annual M+C capitation rate 
is determined on a basis that includes the cost of the NCD service.
    (b) The M+C organization must furnish, arrange or pay for an NCD 
``significant cost'' service before the adjustment of the annual M+C 
capitation rate. The following rules apply to these services:
    (1) Medicare payment for the service is:
    (i) In addition to the capitation payment to the M+C organization; 
and
    (ii) Made directly by the fiscal intermediary and carrier to the M+C 
organization in accordance with original Medicare payment rules, 
methods, and requirements.
    (2) NCD costs for which CMS intermediaries and carriers will not 
make payment and are the responsibility of the M+C organization are--
    (i) Services necessary to diagnose a condition covered by the NCD;
    (ii) Most services furnished as follow-up care to the NCD service;
    (iii) Any service that is already a Medicare-covered service and 
included in the annual M+C capitation rate; and
    (iv) Any service, including the costs of the NCD service itself, to 
the extent the M+C organization is already obligated to cover it as an 
additional benefit under Sec. 422.312 or supplemental benefit under 
Sec. 422.102.
    (3) NCD costs for which CMS intermediaries and carriers make payment 
are--
    (i) Costs relating directly to the provision of services related to 
the NCD that were noncovered services prior to the issuance of the NCD; 
and
    (ii) A service that is not included in the M+C per capita payment 
rate.
    (4) If the M+C organization does not provide or arrange for the 
service consistent with CMS's NCD, enrollees may obtain the services 
through qualified providers not under contract to the M+C organization, 
and the organization will pay for the services consistent with 
Sec. 422.109(c).
    (5) Beneficiaries are liable for any applicable coinsurance amounts, 
but are not responsible for the Part A deductible.
    (c) The term ``significant cost'' as it relates to a particular NCD 
means either of the following:
    (1) The average cost of furnishing a single service exceeds a cost 
threshold that--
    (i) For calendar years 1998 and 1999, is $100,000;
    (ii) For calendar year 2000 and subsequent calendar years, is the 
preceding year's dollar threshold adjusted to reflect the national per 
capita growth percentage described in Sec. 422.254(b).
    (2) The estimated cost of all of Medicare services furnished 
nationwide as a result of a particular NCD represents

[[Page 852]]

at least 0.1 percent of the national standardized annual capitation rate 
(see Sec. 422.254(f)), multiplied by the total number of Medicare 
beneficiaries nationwide for the applicable calendar year.

[63 FR 35077, June 26, 1998, as amended at 65 FR 40321, June 29, 2000]