CMS Pub. 100-16, ch. 4, § 10.2.2

The following circumstances are exceptions to the rule that MAOs must cover the costs

of original Medicare benefits:

• Hospice: Original Medicare (rather than the MAO) will pay the hospice for the

services received by an enrollee who has elected hospice while enrolled in the plan.

For detailed information about services furnished to an enrollee who has elected

hospice care, see section 10.4 below.

• Clinical trials: Original Medicare pays for the costs of routine services provided to an

MA enrollee who joins a qualifying clinical trial. MA plans pay the enrollee the

difference between original Medicare cost-sharing incurred for qualifying clinical

trial items and services and the MA plan’s in-network cost-sharing for the same

category of items and services. For further information on coverage and payment of

clinical trials in MA plans, see section 10.7 below.

• Inpatient stay during which MA enrollment begins: (42 CFR § 422.318) If a Medicare

beneficiary is in an inpatient stay and his enrollment in an MA plan takes effect after

the stay begins, but prior to discharge from that stay:

o Original Medicare is responsible for the costs of that inpatient stay; and

o The beneficiary is responsible for payment of cost-sharing as required under

original Medicare.

In addition to providing original Medicare benefits, the MAO also must furnish, arrange,

or pay for supplemental benefits and prescription drug benefits covered under the plan.

CMS reviews and approves an MAO’s coverage of benefits by ensuring compliance with

requirements described in this manual, including those outlined in this chapter, chapter 8,

“Payments to Medicare Advantage Organizations,” and other applicable CMS guidance,

such as that contained in the annual Call Letter.