CMS Pub. 100-16, ch. 4, § 140.3

This subsection only applies to local MA plans.

CMS will generally approve only full counties in a service area, in order to prevent the

establishment of boundaries that could “game” the county-wide MA payment system by

excluding an area of the county where beneficiaries with expected higher health care

utilization might reside. However, the counties do not need to be contiguous, and under

limited circumstances described below, CMS may approve the inclusion of “partial”

counties in a service area.

CMS will consider approving a service area that includes a partial county, if it determines

that the inclusion of a partial county is: (1) necessary, (2) non-discriminatory, and (3) in

the best interest of the beneficiaries. All three of these factors must be present in order

for CMS to approve an exception to the county integrity rule. CMS may also consider the

extent to which the proposed service area mirrors the service area of existing commercial

health care plans or MA plans offered by the MAO and whether there are other MA plans

serving the entire county.