Explanatory Examples

80.2 – Explanatory Examples (Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15) The following are some examples of CMS’ approach to VAIS: • Example 1: In addition to a plan covering an in-network mandatory supplemental routine vision exam benefit (for which the plan incurs a direct medical cost), it offers as a VAIS a 5% discount on a routine vision exam furnished by an out-of-network vision center. The plan does not incur any medical cost for the out-of-network exam, but does incur some administrative cost to verify enrollee plan membership for the discount and to inform its enrollees about the 5% discount. Analysis: Because the plan does not incur any medical cost in offering the discount for the routine vision exam out-of-network, by definition, the discount cannot be classified as a benefit, and is therefore, eligible to be offered as a VAIS. Furthermore, because the out-of-network routine vision exam is a VAIS, it may neither be advertised to prospective enrollees nor included in the plan bid. • Example 2: An MA plan wishes to offer vouchers for free groceries to its enrollees for which it incurs a minimal cost. Analysis: Grocery vouchers may not be offered as a VAIS if the plan incurs a cost for the vouchers. Although the cost may be minimal, it is not solely administrative and therefore, is not consistent with CMS guidance. • Example 3: An MA plan contracts with a provider or another insurer, such as an insurer for dental or vision services, to furnish non-Medicare covered benefits to its enrollees at a reduced cost. The provider or insurer requires the plan to collect and aggregate payments from its enrollees and to send those payments to the provider or insurer. Analysis: MA plans must include in the plan benefit package all benefits it furnishes by way of a contract with a provider or insurer on behalf of its enrollees and may not contract to offer such a benefit as a VAIS. The plan may not collect payments from its enrollees for services that are not benefits covered by the plan. However, if the provider or insurer in the example offers its services at a discounted rate to the MA plan enrollees, who directly pay the provider or insurer for the services, without additional payment from the plan, then the plan may provide access to this discount as a VAIS.