[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR422.103]



[Page 992-993]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 422_MEDICARE ADVANTAGE PROGRAM--Table of Contents

 

             Subpart C_Benefits and Beneficiary Protections

 

Sec. 422.103  Benefits under an MA MSA plan.



    (a) General rule. An MA organization offering an MA MSA plan must 

make available to an enrollee, or provide reimbursement for, at least 

the services described in Sec. 422.101 after the enrollee incurs 

countable expenses equal to the



[[Page 993]]



amount of the plan's annual deductible.

    (b) Countable expenses. An MA organization offering an MA MSA plan 

must count toward the annual deductible at least all amounts that would 

be paid for the particular service under original Medicare, including 

amounts that would be paid by the enrollee as deductibles or 

coinsurance.

    (c) Services after the deductible. For services received by the 

enrollee after the annual deductible is satisfied, an MA organization 

offering an MA MSA plan must pay, at a minimum, the lesser of the 

following amounts:

    (1) 100 percent of the expense of the services.

    (2) 100 percent of the amounts that would have been paid for the 

services under original Medicare, including amounts that would be paid 

by the enrollee as deductibles and coinsurance.

    (d) Annual deductible. The annual deductible for an MA MSA plan--

    (1) For contract year 1999, may not exceed $6,000; and

    (2) For subsequent contract years may not exceed the deductible for 

the preceding contract year, increased by the national per capita growth 

percentage determined under Sec. 422.306(a)(2).



[63 FR 35077, June 26, 1998, as amended at 70 FR 4720, Jan. 28, 2005; 70 

FR 52026, Sept. 1, 2005]