Services by Outside Sources Not Covered

40.1.2 - Services by Outside Sources Not Covered (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) Where Medicare is secondary payer for a person enrolled in an employer sponsored managed care health plan (e.g., Health Maintenance Organization (HMO)/Competitive Medicare Plan (CMP)), Medicare does not pay for services obtained from a source outside the employer-sponsored managed care health plan if: • The same type of services could have been obtained as covered services through, or paid for by, the managed care employer health plan, or • The particular services can be paid for by the plan (e.g., emergency or urgently needed services). Medicare benefits are precluded under these circumstances even if the individual receives services outside of the managed care health plan's service area, e.g., while the individual is away from home. At the time of admission, providers are to ask beneficiaries that are enrolled in GHPs whether the plan is a managed care health plan. If the individual is enrolled in such a plan, Medicare is not billed. (However, a no-payment bill is required to be sent to the A/B MACs (Part A) per Chapter 3, §40.1.) NOTE: This restriction only affects Medicare beneficiaries enrolled in employer sponsored managed care health plans that either do not have a Medicare contract or have a Medicare cost contract. Beneficiaries in HMO/CMPs that have Medicare risk contracts are not affected because beneficiaries enrolled in a risk-basis HMO/CMP are locked into the plan in all instances except for emergency or urgently needed services.