Exception

40.1.2.1 - Exception (Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22) If a beneficiary obtains services from a source outside the managed care GHP, and has not been notified in writing of this special rule, Medicare pays, provided the plan will not pay for legitimate reasons. In general, it is assumed that written notification has not been given in the absence of evidence to the contrary, e.g., the A/B MAC’s internal system indicates that the beneficiary is a working aged, ESRD, or disabled beneficiary who belongs to a managed care GHP and that the beneficiary has been notified that Medicare will not pay. Where payment is made for services from a source outside the managed care health plan, the Medicare Benefits Notice (Form CMS-1533), or the MSN, where applicable, states the following: Our records show that you are a member of an employer sponsored managed care health plan. Since Medicare is secondary payer for you, services from sources outside your health plan are not covered. However, since you were not previously notified of this, we will pay this time. In the future, payment will not be made for non-plan services that could have been obtained from or through the prepaid health plan (PHP). A/B MACs and DME MACs may systematically keep this information in their system so the A/B MACs and DME MACs may alert the beneficiary of the one-time notification of going outside the managed care GHP network.