Out-of-Area, Out-of-Network and Extended Absence

50 - Out-of-Area, Out-of-Network and Extended Absence (Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05) Services obtained from non-network providers (when not referred) are covered under the Fee-For-Service program (and thus subject to Medicare Fee-For-Service coinsurance and deductible requirements), unless they are emergency or urgently needed services. For emergency or urgently needed services the Medicare cost plan is liable for reimbursement and the contracted member cost sharing applies. Emergency and urgently needed services are defined in §10.2 of this subpart. As discussed in further detail in the enrollment section of this chapter Medicare cost plans must disenroll an individual if that individual has permanently moved from the Medicare cost plan’s geographic area. An uninterrupted absence of 90 days is deemed to be a permanent move and the individual must be disenrolled unless the Medicare cost plan offers an extended absence option (42 CFR 417.460). A Medicare cost plan that chooses to offer an extended absence option may retain members who temporarily (more than 90 days but less than one year) leave the geographic area but remain in the United States either: • By paying for all covered services for such members based on mutually agreeable restrictions; or • By providing services through an affiliated organization (42 CFR 417.460(f)(2)). (42 CFR 417.460(f)(2)(ii)-(iii)) A Medicare cost plan that chooses to exercise this exception must make the option available to all Medicare enrollees who are absent for an extended period from their geographic areas. However, a Medicare cost plan may limit this option to enrollees who go to a geographic area served by an affiliated Medicare cost plan. When a Medicare cost plan offers an extended absence option it must provide all Part A and Part B services; however, non-Part D supplemental benefits may be discontinued on leaving the geographic area as long as the member is not required to continue paying the premium or portion of a premium that corresponds to these services.