National Coverage Determination (NCDs) services that are considered a significant cost

66 - National Coverage Determination (NCDs) services that are considered a significant cost for Medicare Advantage Plans (Rev. 10229, Issued: 07-21-20 Effective: 10-01-20, Implementation: 10-05-20) CMS is streamlining the editing for MA plans’ claims when it is determined that certain services are being disallowed on MA plans that are considered a significant cost under section 422.109(a)(2) of title 42 of the Code of Federal Regulations. Original fee-for-service Medicare will pay for services obtained by beneficiaries enrolled in Medicare Advantage (MA) plans in this circumstance. Consistent with §1862 (t)(2) of the Social Security Act, Medicare Administrative Contractors will pay for identified significant cost services for Medicare beneficiaries enrolled in MA plans. In addition 42 CFR §422.109, the Medicare payment for the services or benefit is made directly by the A/B MAC to the provider furnishing the service or benefit in accordance with original Medicare payment, rules, methods, and requirements. Beneficiaries are liable for any applicable coinsurance amounts. Cost for NCD services legislative changes in benefits for which CMS A/B MACs will not make payment and are the responsibility of the M+C organization are: I. Services necessary to diagnose a condition covered by the NCD or legislative changes in benefits; II. Most services furnished as follow up care to the NCD services or legislative changes in benefits; III. Any services that is already a Medicare-covered service and included in the annual M+C capitation rate or previously, adjusted payments; and IV. Any services, including costs of the NCD service or legislative change in benefits, to the extent the M+C organization is already obligated to cover it as an additional benefit under 42CFR §422.312 or supplemental benefit under 42 CFR §422.102.