[Code of Federal Regulations] [Title 42, Volume 3] [Revised as of October 1, 2006] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR422.100] [Page 249-250] 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. 422.100 General requirements. Source: 63 FR 35077, June 26, 1998, unless otherwise noted. (a) Basic rule. Subject to the conditions and limitations set forth in this subpart, an MA organization offering an MA plan must provide enrollees in that plan with coverage of the basic benefits described in paragraph (c) of this section (and, to the extent applicable, the benefits described in Sec. 422.102) by furnishing the benefits directly or through arrangements, or by paying for the benefits. CMS reviews these benefits subject to the requirements of Sec. 422.100(g) and the requirements in subpart G of this part. (b) Services of noncontracting providers and suppliers. (1) An MA organization must make timely and reasonable payment to or on behalf of the plan enrollee for the following services obtained from a provider or supplier that does not contract with the MA organization to provide services covered by the MA plan: (i) Ambulance services dispatched through 911 or its local equivalent as provided in Sec. 422.113. (ii) Emergency and urgently needed services as provided in Sec. 422.113. (iii) Maintenance and post-stabilization care services as provided in Sec. 422.113. (iv) Renal dialysis services provided while the enrollee was temporarily outside the plan's service area. (v) Services for which coverage has been denied by the MA organization and found (upon appeal under subpart M of this part) to be services the enrollee was entitled to have furnished, or paid for, by the MA organization. (2) An MA plan (and an MA MSA plan, after the annual deductible in Sec. 422.103(d) has been met) offered by an MA organization satisfies paragraph (a) of this section with respect to benefits for services furnished by a noncontracting provider if that MA plan provides payment in an amount the provider would have received under original Medicare (including balance billing permitted under Medicare Part A and Part B). (c) Types of benefits. An MA plan includes at a minimum basic benefits, and also may include mandatory and optional supplemental benefits. [[Page 250]] (1) Basic benefits are all Medicare-covered services, except hospice services. (2) Supplemental benefits, which consist of-- (i) Mandatory supplemental benefits are services not covered by Medicare that an MA enrollee must purchase as part of an MA plan that are paid for in full, directly by (or on behalf of) Medicare enrollees, in the form of premiums or cost-sharing. (ii) Optional supplemental benefits are health services not covered by Medicare that are purchased at the option of the MA enrollee and paid for in full, directly by (or on behalf of) the Medicare enrollee, in the form of premiums or cost-sharing. These services may be grouped or offered individually. (d) Availability and structure of plans. An MA organization offering an MA plan must offer it-- (1) To all Medicare beneficiaries residing in the service area of the MA plan; (2) At a uniform premium, with uniform benefits and level of cost- sharing throughout the plan's service area, or segment of service area as provided in Sec. 422.262(c)(2). (e) Multiple plans in one service area. An MA organization may offer more than one MA plan in the same service area subject to the conditions and limitations set forth in this subpart for each MA plan. (f) CMS review and approval of MA benefits. CMS reviews and approves MA benefits using written policy guidelines and requirements in this part and other CMS instructions to ensure that-- (1) Medicare-covered services meet CMS fee-for-service guidelines; (2) MA organizations are not designing benefits to discriminate against beneficiaries, promote discrimination, discourage enrollment or encourage disenrollment, steer subsets of Medicare beneficiaries to particular MA plans, or inhibit access to services; and (3) Benefit design meets other MA program requirements. (g) Benefits affecting screening mammography, influenza vaccine, and pneumoccal vaccine. (1) Enrollees of MA organizations may directly access (through self-referral) screening mammography and influenza vaccine. (2) MA organizations may not impose cost-sharing for influenza vaccine and pneumococcal vaccine on their MA plan enrollees. (h) Requirements relating to Medicare conditions of participation. Basic benefits must be furnished through providers meeting the requirements in Sec. 422.204(b)(3). (i) Provider networks. The MA plans offered by an MA organization may share a provider network as long as each MA plan independently meets the access and availability standards described at Sec. 422.112, as determined by CMS. [65 FR 40319, June 29, 2000, as amended at 67 FR 13288, Mar. 22, 2002; 70 FR 4719, Jan. 28, 2005; 70 FR 52026, Sept. 1, 2005]