Provider Services Furnished by the Cost-Based HMO/CMPs

50 - Provider Services Furnished by the Cost-Based HMO/CMPs Through Arrangements (Rev. 4, 10-01-01) Costs of covered services the cost-based HMO/CMP furnishes to Medicare enrollees through arrangements with non-plan providers will, in most cases, be the amount the HMO/CMP pays the provider under its financial arrangement, to the extent it is found reasonable (subject to the rules in Chapter 17 (Subchapters A and B)). The apportionment process used to determine the reasonable cost of, or prospective payment for, provider services furnished to the Medicare enrollees must be on the same basis that is used by the provider in determining the reasonable cost of, or prospective payment for, provider services furnished to Medicare beneficiaries who are not cost-based HMO/CMP enrollees, subject to the rules set forth in Chapter 17. However, if the special nature or terms of the cost-based HMO/CMP’s financial arrangements with the provider would result in the Medicare program bearing the costs of delivering care to individuals other than Medicare enrollees of the cost-based HMO/CMP, the apportionment must be on some other appropriate basis approved by CMS intended to assure that the share allocated to the Medicare program does not include costs of delivering care to non-Medicare enrollees. When the HMO/CMP elects to have hospital or skilled nursing facility providers seek reimbursement directly from the Fee-For-Service (FFS) system for covered services furnished to the HMO/CMP’s Medicare enrollees, the share to be borne by CMS is the amount that the FFS system pays the provider. This will be determined on the same approved basis otherwise used by the hospital or skilled nursing facility provider in apportioning Medicare’s share of allowable costs or the Medicare prospective payment for covered services furnished Medicare beneficiaries who are not enrollees of the HMO/CMP.