[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: 42CFR422.106]

[Page 254-255]
 
                         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 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

[[Page 255]]

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]