42 C.F.R. § 422.105 Special rules for self-referral and point of service option.
Title 42 - Public Health
(a) Self-referral. When an MA plan member receives an item or service of the plan that is covered upon referral or pre-authorization from a contracted provider of that plan, the member cannot be financially liable for more than the normal in-plan cost sharing, if the member correctly identified himself or herself as a member of that plan to the contracted provider before receiving the covered item or service, unless the contracted provider can show that the enrollee was notified prior to receiving the item or service that the item or service is covered only if further action is taken by the enrollee. (b) Point of service option. As a general rule, a POS benefit is an option that an MA organization may offer in an MA coordinated care plan to provide enrollees with additional choice in obtaining specified health care services. The organization may offer A POS option— (1) Before January 1, 2006, under a coordinated care plan as an additional benefit as described in section 1854(f)(1)(A) of the Act; (2) Under a coordinated care plan as a mandatory supplemental benefit as described in §422.102(a); or (3) Under a coordinated care plan as an optional supplemental benefit as described in §422.102(b). (4) An MA regional plan or local MA PPO is permitted to offer a POS–LIKE benefit as described in paragraphs (b)(2) or (b)(3) of this section as a supplemental benefit. An MA regional plan or local MA PPO may offer a POS–LIKE option as a supplemental benefit where cost sharing for out-of-network services is reduced, in a limited manner, for services obtained from out-of-network providers. Offering a POS–LIKE supplemental benefit does not affect the MA regional plan's or local MA PPO's responsibility to provide reimbursement for all covered benefits, regardless of whether those benefits are provided within the network of contracted providers. (c) Ensuring availability and continuity of care. An MA network plan that includes a POS benefit must continue to provide all benefits and ensure access as required under this subpart. (d) Enrollee information and disclosure. The disclosure requirements specified in §422.111 apply in addition to the following requirements: (1) Written rules. MA organizations must maintain written rules on how to obtain health benefits through the POS benefit. (2) Evidence of coverage document. The MA organization must provide to beneficiaries enrolling in a plan with a POS benefit an “evidence of coverage” document, or otherwise provide written documentation, that specifies all costs and possible financial risks to the enrollee, including— (i) Any premiums and cost-sharing for which the enrollee is responsible; (ii) Annual limits on benefits and on out-of-pocket expenditures; (iii) Potential financial responsibility for services for which the plan denies payment because they were not covered under the POS benefit, or exceeded the dollar limit for the benefit; and (iv) The annual maximum out-of-pocket expense an enrollee could incur. (e) Prompt payment. Health benefits payable under the POS benefit are subject to the prompt payment requirements in §422.520. (f) POS-related data. An MA organization that offers a POS benefit through an MA plan must report enrollee utilization data at the plan level by both plan contracting providers (in-network) and by non-contracting providers (out-of-network) including enrollee use of the POS benefit, in the form and manner prescribed by CMS. [63 FR 35077, June 26, 1998, as amended at 65 FR 40320, June 29, 2000; 70 FR 4721, Jan. 28, 2005]
Title 42: Public Health
PART 422—MEDICARE ADVANTAGE PROGRAM
Subpart C—Benefits and Beneficiary Protections
§ 422.105 Special rules for self-referral and point of service option.
