When the Significant Cost Criterion is Met

90.3.2 – When the Significant Cost Criterion is Met (Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15) Prior to the adjustment of the annual MA capitation rate, if CMS determines and announces that an individual NCD item, service or legislative change in benefits does meet a criterion for significant cost, then plans are not required to assume risk for the costs of that service or benefit until the contract year for which payments are appropriately adjusted to take into account the significant cost of the service or benefit. However, a plan must pay for the following: • Diagnostic services related to the NCD item, service, or legislative change in benefits and most follow-up services related to the NCD item, service, or legislative change (42 CFR § 422.109(c)(2)(i),(ii)); • NCD items, services, or legislative change to benefits that are already included in the plan’s benefit package either as original Medicare benefits or supplemental benefits. Although the item or service may not be specifically included in the services MAOs must cover under their contract with CMS, MAOs must still provide access to the NCD item or service by furnishing or arranging for the service. The MACs are responsible for reimbursements for NCD items, services, or legislative changes that are not the legal obligation of the MAO.