Financial Responsibility - General

40.1 - Financial Responsibility - General (Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05) (42 CFR 417.414( c )) The Medicare cost plan assumes financial responsibility to provide reasonable reimbursement to its enrollees for: • Emergency services; and • Urgently needed services (as defined above); even: • From providers and suppliers outside the Medicare cost plan; and even: • In the absence of the Medicare cost plan’s prior approval. The Medicare cost plan also assumes financial responsibility for: • Services that were initially denied, but later granted, due to an appeal by the enrollee. (42 CFR 417.452) A Medicare cost plan may impose: • Deductibles; • Coinsurance; or • Copays; for any of the services which it provides except for influenza vaccines for which no copays may be charged. The Medicare cost plan may impose annual, semi-annual, quarterly, monthly or any other periodic limits on the Optional Supplemental Benefits it offers its enrollees provided these limits are not prohibited by State law. The Medicare cost plan may not impose caps on any Medicare covered benefit unless original Medicare also imposes a cap (for example, the 100-day limit on SNF benefits). The deductibles and coinsurances may be paid by or on behalf of the enrollee in the form of a: • Premium; • Membership fee; • Charge per unit; or • Other similar charge. (42 CFR 417.454) The Medicare cost plan must agree to charge its Medicare enrollees only for the: • Deductible and coinsurance amounts applicable to furnished Medicare covered services; • Premium and cost-sharing charges for services offered as supplemental benefits provided that the sum of the amounts the Medicare cost plan charges its Medicare enrollees for these services does not exceed the actuarial value for those services (42 CFR 417.452(d)(3)); • Charges for services not covered under the plan; and • Services for which Medicare is not the primary payer if payment for the services has been made to the enrollee (42 CFR 417.528(b)(2)).