Exceptions to Requirement for MA plans to Cover FFS Benefits

10.2.2 – Exceptions to Requirement for MA plans to Cover FFS Benefits (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) The following circumstances are exceptions to the rule that MAOs must cover the costs of original Medicare benefits: • Hospice: Original Medicare (rather than the MAO) will pay the hospice for the services received by an enrollee who has elected hospice while enrolled in the plan. For detailed information about services furnished to an enrollee who has elected hospice care, see section 10.4 below. • Clinical trials: Original Medicare pays for the costs of routine services provided to an MA enrollee who joins a qualifying clinical trial. MA plans pay the enrollee the difference between original Medicare cost-sharing incurred for qualifying clinical trial items and services and the MA plan’s in-network cost-sharing for the same category of items and services. For further information on coverage and payment of clinical trials in MA plans, see section 10.7 below. • Inpatient stay during which MA enrollment begins: (42 CFR § 422.318) If a Medicare beneficiary is in an inpatient stay and his enrollment in an MA plan takes effect after the stay begins, but prior to discharge from that stay: o Original Medicare is responsible for the costs of that inpatient stay; and o The beneficiary is responsible for payment of cost-sharing as required under original Medicare. In addition to providing original Medicare benefits, the MAO also must furnish, arrange, or pay for supplemental benefits and prescription drug benefits covered under the plan. CMS reviews and approves an MAO’s coverage of benefits by ensuring compliance with requirements described in this manual, including those outlined in this chapter, chapter 8, “Payments to Medicare Advantage Organizations,” and other applicable CMS guidance, such as that contained in the annual Call Letter.