Medicare Managed Care Manual (Pub. 100-16), Ch. 16a § 80.2.1
Advance Notice for Hospital Services
80.2.1 - Advance Notice for Hospital Services
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11)
42 CFR 422.216(d)(2)
PFFS plans must require a deemed or direct-contracting hospital that intends to impose
balance billing to provide members, before furnishing any hospital services for which the
balance billing amount could be greater than $500, with the following:
(1) A notice that balance billing is permitted for those services;
(2) A good faith estimate of the likely amount of balance billing based on the
member’s presenting condition; and
(3) The amount of any deductible, coinsurance, and copayment that may be due in
addition to the balance billing amount.
The PFFS plan must include these requirements in its terms and conditions of payment
for deemed hospitals or in the signed contract or agreement between the plan and the
direct-contracting hospital.