Provider Services Furnished Directly by Cost-Based HMO/CMPs

40 - Provider Services Furnished Directly by Cost-Based HMO/CMPs (Rev. 4, 10-01-01) When a provider owned or operated by the cost-based HMO/CMP, or related to the HMO/CMP by common ownership or control (referred to here as a "plan provider"), furnishes services directly to the HMO/CMP’s enrollees, it is subject to the same cost finding and apportionment requirements or the prospective payment system applicable to other providers under Medicare. These are set forth in Chapters 23 and 28 of the Medicare Provider Reimbursement Manual (Pub. 15), Part I. An approved method of cost finding described in that manual must be used to determine the actual cost of covered services furnished directly by the HMO/CMP during the reporting period. The essential difference between cost-based HMO/CMP and non-HMO/CMP (i.e., unrelated) providers is that a cost-based plan provider will, in effect, have two separate reimbursement settlements with the Medicare program. It will have, one for Medicare patients who are not enrolled in the cost-based HMO/CMP, and one for Medicare beneficiaries who are cost-based HMO/CMP enrollees.