[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: 42CFR422.109]



[Page 996-997]

 

                         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. 422.109  Effect of national coverage determinations (NCDs) and 

legislative changes in benefits.



    (a) Definitions. The term significant cost, as it relates to a 

particular NCD or legislative change in benefits, 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; and

    (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. 422.308(a).

    (2) 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.

    (b) General rule. If CMS determines and announces that an individual 

NCD or legislative change in benefits meets the criteria for significant 

cost described in paragraph (a) of this section, a MA organization is 

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 cost of the NCD service or legislative change in 

benefits. If CMS determines that an NCD or legislative change in 

benefits does not meet the ``significant cost'' threshold described in 

Sec. 422.109(a), the MA organization 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 stated in the 

NCD or specified in the legislation.

    (c) Before payment adjustments become effective. Before the contract 

year that payment adjustments that take into account the significant 

cost of the NCD service or legislative change in benefits become 

effective, the service or benefit is not included in the MA 

organization's contract with CMS, and is not a covered benefit under the 

contract. The following rules apply to these services or benefits:

    (1) Medicare payment for the service or benefit is made directly by 

the fiscal intermediary and carrier to the provider furnishing the 

service or benefit in accordance with original Medicare payment rules, 

methods, and requirements.

    (2) Costs for NCD services or legislative changes in benefits for 

which CMS intermediaries and carriers will not make payment and are the 

responsibility of the MA organization are--

    (i) Services necessary to diagnose a condition covered by the NCD or 

legislative changes in benefits;

    (ii) Most services furnished as follow-up care to the NCD service or 

legislative change in benefits;

    (iii) Any service that is already a Medicare-covered service and 

included in the annual MA capitation rate or previously adjusted 

payments; and

    (iv) Any services, including the costs of the NCD service or 

legislative change in benefits, to the extent the MA organization is 

already obligated to cover it as a supplemental benefit under Sec. 

422.102.

    (3) Costs for significant cost NCD services or legislative changes 

in benefits for which CMS fiscal intermediaries and carriers will make 

payment are those Medicare costs not listed in paragraphs (c)(2)(i) 

through (c)(2)(iv) of this section.

    (4) Beneficiaries are liable for any applicable coinsurance amounts.

    (d) After payment adjustments become effective. For the contract 

year in which payment adjustments that take into account the significant 

cost of the NCD service or legislative change in benefits are in effect, 

the service or benefit is included in the MA organization's contract 

with CMS, and is a covered benefit under the contract. Subject to all 

applicable rules under this part, the MA organization must furnish, 

arrange, or pay for the NCD service or legislative change in benefits. 

MA organizations may establish separate plan rules for these services 

and



[[Page 997]]



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 Medicare enrollee will be 

responsible for MA plan cost sharing, as approved by CMS or unless 

otherwise instructed by CMS.



[68 FR 50856, Aug. 22, 2003, as amended at 70 FR 4721, Jan. 28, 2005; 70 

FR 52026, Sept. 1, 2005]