CMS Pub. 100-05, ch. 5, § 40.1.2.1

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.