Source: https://www.law.cornell.edu/cfr/text/42/422.105
Timestamp: 2016-05-01 12:43:27
Document Index: 768255933

Matched Legal Cases: ['art 422', '§ 422', '§ 422', '§ 422', '§ 422', '§ 422']

42 CFR 422.105 - Special rules for self-referral and point of service option. | US Law | LII / Legal Information Institute
CFR › Title 42 › Chapter IV › Subchapter B › Part 422 › Subpart C › Section 422.105 42 CFR 422.105 - Special rules for self-referral and point of service option.
Point of service option.
Before January 1, 2006, under a coordinated care plan as an additional benefit as described in section 1854(f)(1)(A) of the Act;
Under an HMO plan as a mandatory supplemental benefit as described in § 422.102(a); or
Under an HMO plan as an optional supplemental benefit as described in § 422.102(b).
Ensuring availability and continuity of care.
Enrollee information and disclosure.
Evidence of coverage document.
Any premiums and cost-sharing for which the enrollee is responsible;
Annual limits on benefits and on out-of-pocket expenditures;
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
The annual maximum out-of-pocket expense an enrollee could incur.
POS-related data.
§ 422.105 Special rules for self-referral and point of service option.
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.
Point of service option. As a general rule, a POS benefit is an option that an MA organization may offer in an HMO 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;
Ensuring availability and continuity of care. An MA HMO plan that includes a POS benefit must continue to provide all benefits and ensure access as required under this subpart.
Enrollee information and disclosure. The disclosure requirements specified in § 422.111 apply in addition to the following requirements:
Written rules. MA organizations must maintain written rules on how to obtain health benefits through the POS benefit.
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;
Prompt payment. Health benefits payable under the POS benefit are subject to the prompt payment requirements in § 422.520.
POS-related data. An MA organization that offers a POS benefit through an HMO 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.