CMS Pub. 100-16, ch. 6, § 100

Consistent with §1852(a)(2) and §1852(k)(1) of the Social Security Act, non-contract

providers must accept as payment in full payment amounts applicable in Original

Medicare. Thus, this provision of law imposes a cap on payment to non-contract

providers of provider payment amounts plus beneficiary cost-sharing amounts applicable

in Original Medicare, and ensures that non-contract providers not balance bill MA plan

enrollees for other than MA plan cost-sharing amounts.

• Note that non-contract facility providers identified at §1861(u) of the Social

Security Act (the Act), which includes hospitals, skilled nursing facilities and

home health agencies, must accept as payment in full payment amounts

applicable in Original Medicare less any payments under 42 CFR 412.105(g)

concerning indirect medical education payment to hospitals for managed care

enrollees and 42 CFR 413.86(d) concerning payment for direct graduate medical

education costs.

• In cases where the MA organization has not arranged for the services, if the non-contract provider’s bill is less than the Original Medicare amount, the MA

organization is only required to pay the billed amount.

In addition, under Federal law, non-contract providers are subject to penalties if they

accept more than Original Medicare amounts.

(Source: 42 CFR 422.214 and preamble to June 29, 2000, rule.)