Guidance on Other Enrollee Out-of-Pocket Liability

50.5 – Guidance on Other Enrollee Out-of-Pocket Liability (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) Missed Appointment and Other Charges: MA plans may charge "administrative fees" to enrollees for missed appointments with contracting providers and for not paying contracting providers required cost-sharing at the time of service. Under the MA program, such charges are allowable only if the charge is priced in the bid and documentation submitted with the bid clearly shows these charges. Furthermore, those additional charges must be clearly outlined in the notes section of the PBP and in the Evidence of Coverage and ANOC, as applicable. Contracted and non-contracted providers may charge a fee for missed appointments, provided such fees apply uniformly to all Medicare and non-Medicare patients. This applies even if the MAO itself does not charge an administrative fee for missed appointments. Neither MA plans nor their contracted providers may require enrollees to create a fund or ‘escrow account’ for a provider to ensure payment of missed appointment fees. Such a practice creates a barrier to access to care and violates CMS anti-discrimination regulations. No balance billing: As indicated in section 170 below, an enrollee is responsible for paying non-contracted providers only the plan-allowed cost-sharing for covered services. The MA plan, not the enrollee, is obligated to pay balance billing when it is allowed under Medicare rules. Furthermore, if an enrollee inadvertently paid balance billing which is the plan’s responsibility, the plan must refund the balance billing amount to the enrollee. No reimbursement relationship: Plans may not require enrollees to pay a contracted provider more than the plan’s specified cost-sharing for Part A and Part B services; that is, plans may not require enrollees to pay the plan’s share of the costs for a service and then reimburse the enrollee.