[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: 42CFR422.106]



[Page 994-995]

 

                         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. 422.106  Coordination of benefits with employer or union group 

health plans and Medicaid.



    (a) General rule. If an MA organization 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. Jurisdiction regulating benefits under these 

circumstances is as follows:

    (1) All requirements of this part that apply to the MA program apply 

to the MA plan coverage and benefits provided to enrollees eligible for 

benefits under an employer, labor organization, trustees of a fund 

established by one or more employers or labor organizations, or Medicaid 

contract.

    (2) Employer benefits that complement an MA plan, which are not part 

of the MA plan, are not subject to review or approval by CMS.

    (3) Medicaid benefits are not reviewed under this part, but are 

subject to appropriate CMS review under the Medicaid program. MA plan 

benefits provided to individuals entitled to Medicaid benefits provided 

by the MA organization under a contract with the State Medicaid agency 

are subject to MA rules and requirements.

    (b) Examples. Permissible employer, labor organization, benefit fund 

trustee, or Medicaid plan benefits include the following:

    (1) Payment of a portion or all of the MA basic and supplemental 

premiums.

    (2) Payment of a portion or all of other cost-sharing amounts 

approved for the MA plan.

    (3) Other employer-sponsored benefits that may require additional 

premium and cost-sharing, or other benefits provided by the organization 

under a contract with the State Medicaid agency.

    (c) Waiver or modification of contracts with MA organizations. (1) 

MA organizations may request, in writing, from CMS, a waiver or 

modification of those requirements in this part that hinder the design 

of, the offering of, or the enrollment in, MA plans under contracts 

between MA organizations and employers, labor organizations, or the 

trustees



[[Page 995]]



of funds established by one or more employers or labor organizations to 

furnish benefits to the entity's employees, former employees, or members 

or former members of the labor organizations.

    (2) Approved waivers or modifications under this paragraph granted 

to any MA organization may be used by any other similarly situated MA 

organization in developing its bid.

    (d) Employer sponsored MA plans for plan years beginning on or after 

January 1, 2006. (1) CMS may waive or modify any requirement in this 

part or Part D that hinders the design of, the offering of, or the 

enrollment in, an MA plan (including an MA-PD plan) offered by one or 

more employers, labor organizations, or the trustees of a fund 

established by one or more employers or labor organizations (or 

combination thereof), or that is offered, sponsored or administered by 

an entity on behalf of one or more employers or labor organizations, to 

furnish benefits to the employers' employees, former employees (or 

combination thereof) or members or former members (or combination 

thereof) of the labor organizations. Any entity seeking to offer, 

sponsor, or administer such an MA plan described in this paragraph may 

request, in writing, from CMS, a waiver or modification of requirements 

in this part that hinder the design of, the offering of, or the 

enrollment in, such MA plan.

    (2) An MA plan described in this paragraph may restrict the 

enrollment of individuals in that plan to individuals who are 

beneficiaries and participants in that plan.

    (3) Approved waivers or modifications under this paragraph granted 

to any MA plan may be used by any other similarly situated MA plan in 

developing its bid.



[65 FR 40320, June 29, 2000, as amended at 68 FR 50856, Aug. 22, 2003; 

70 FR 4721, Jan. 28, 2005]