Services for Which MA Plans Must Pay Non-contracted

110.1.3 – Services for Which MA Plans Must Pay Non-contracted Providers and Suppliers (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) All MAOs must make timely and reasonable payment to, or on behalf of, plan enrollees for the following services obtained from a provider or supplier that does not contract with the MAO: • Ambulance services dispatched through 911 or its local equivalent where other means of transportation would endanger the beneficiary’s health, as provided in section 20.1 of this chapter; • Emergency and urgently needed services under the circumstances described in sections 20.2 through 20.4 of this chapter; • Maintenance and post-stabilization care services under the circumstances described in section 20.5 of this chapter; • Medically necessary dialysis from any qualified provider selected by an enrollee when the enrollee is temporarily absent from the plan’s service area and cannot reasonably access the plan’s contracted dialysis providers. An MA plan cannot require prior authorization or notification for these services. However, the MA plan may provide medical advice and recommend that the enrollee use a qualified dialysis provider if the enrollee voluntarily requests such advice because he/she will be out of area. The MA plan must clearly inform the enrollee that the plan will pay for care from any qualified dialysis provider the enrollee may independently select. Furthermore, the cost-sharing for out-of-network medically necessary dialysis may not exceed the cost-sharing for in-network dialysis; • Services for which coverage has been denied by the MAO and found (upon appeal under subpart M of 42 CFR Part 422) to be services the enrollee was entitled to have furnished, or paid for, by the MAO; and • Regardless of the MA plan type being offered, arrange for specialty care outside of the network, but at in-network cost-sharing, in order to provide all Medicare Part A and Part B benefits. That is, if an enrollee requires a very specialized covered service that is not provided by the physicians in the network, the plan must arrange for that service to be provided by a qualified non-contracted provider. An MA plan (and an MA MSA plan, after the annual deductible has been met) offered by an MAO generally satisfies its requirements of providing basic benefits with respect to benefits for services furnished by a non-contracting provider if that MA plan provides payment in an amount the provider would have been entitled to collect under original Medicare (see section 170 for guidance on balance billing). MAOs may negotiate payment amounts with their contracted providers and need not follow original Medicare payment rates. However, in the absence of a mutual agreement between the non-contracted provider and the MAO to receive less than the original Medicare rate, non-contracted providers must accept the original Medicare amount as payment in full. For further information on payment to non-contracted providers and suppliers refer to chapter 6, “Relationships with Providers,” of the MMCM. Additional useful information on payment requirements by MAOs to non-network providers may be found in the “MA Payment Guide for Out-of-network Payments,” at: http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/downloads/oon-payments.pdf. When an enrollee visits an in-network provider, even though that in-network provider may work with an out of network provider, (e.g., a diagnostic lab that sends specimens to a central location), then the enrollee is only responsible for in-network cost-sharing. For further information on an MA plan’s obligation to pay non-contracted providers when a referral to such a provider was made, see section 160 below.