Special Rules for Services Furnished by Non-Contract Providers

100 - Special Rules for Services Furnished by Non-Contract Providers (Rev. 24, 06-06-03) Consistent with §1852(a)(2) and §1852(k)(1) of the Social Security Act, non-contract providers must accept as payment in full payment amounts applicable in Original Medicare. Thus, this provision of law imposes a cap on payment to non-contract providers of provider payment amounts plus beneficiary cost-sharing amounts applicable in Original Medicare, and ensures that non-contract providers not balance bill MA plan enrollees for other than MA plan cost-sharing amounts. • Note that non-contract facility providers identified at §1861(u) of the Social Security Act (the Act), which includes hospitals, skilled nursing facilities and home health agencies, must accept as payment in full payment amounts applicable in Original Medicare less any payments under 42 CFR 412.105(g) concerning indirect medical education payment to hospitals for managed care enrollees and 42 CFR 413.86(d) concerning payment for direct graduate medical education costs. • In cases where the MA organization has not arranged for the services, if the non- contract provider’s bill is less than the Original Medicare amount, the MA organization is only required to pay the billed amount. In addition, under Federal law, non-contract providers are subject to penalties if they accept more than Original Medicare amounts. (Source: 42 CFR 422.214 and preamble to June 29, 2000, rule.)