CMS Pub. 100-11, ch. 13, § 40.3

Nearly all Medicare participants have both Part A and Part B, and the capitation amount

that Medicare pays is the sum of the Part A and Part B capitation rates. However, Section

1894(a)(1) of the Act permits a PACE program eligible individual who is entitled to

Medicare benefits under Part A or enrolled under Part B to enroll in the PACE program.

For persons who are eligible under only one part of Medicare, the Medicare capitation

amount will be only the portion for that part. Such a participant is required to make up the

difference through payment of an additional premium amount equal to the missing piece

of the Medicare capitation amount. The premiums for Medicare-only participants are as

follows:

• For a participant who is entitled to Medicare Part A and enrolled under

Medicare Part B, but is not eligible for Medicaid, the premium equals the

Medicaid capitation amount;

• For a participant who is entitled to Medicare Part A, but is not enrolled under

Part B and is not eligible for Medicaid, the premium equals the Medicaid

capitation amount plus the Medicare Part B capitation rate;

• For a participant who is enrolled only under Medicare Part B and is not

eligible for Medicaid, the premium equals the Medicaid capitation amount

plus the Medicare Part A capitation rate.

No premium may be charged to a participant who is dually eligible for both Medicare and

Medicaid or who is only eligible for Medicaid.

[42 CFR § 460.186; 71 FR 71322 (Dec. 8, 2006)]