Cap On Beneficiary Monetary Responsibility

10.8 - Cap On Beneficiary Monetary Responsibility (Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05) (Chapter 4, §10.4 of the Medicare Managed Care Manual): A Medicare cost plan enrollee should never pay more than the plan required cost sharing – coinsurance, deductibles and copays. This cap on beneficiary liability holds even: • If a provider or delegated provider declares insolvency resulting in a plan loss; • If a non-contracted provider which provided services to the enrollee, for emergent or urgent care is entitled to balanced billing; and • This cap on beneficiary liability prohibits a plan from requiring a beneficiary to first pay a contracted provider, except for copayments, and then receive reimbursement from the Medicare cost organization.