CMS Pub. 100-16, ch. 8, § 10.1

This chapter discusses payment rules for the three general types of MA plans:

1. Coordinated Care Plan (CCP), which includes HMOs, HMO-POS plans, PPOs

(both local and regional), provider-sponsored organizations (PSOs), and special

needs plans (SNPs);

2. Private Fee-for-Service (PFFS) Plan; and

3. Medical Savings Account (MSA) Plan, which is a combination of a high

deductible health plan for coverage of original Medicare benefits and a deposit

into the enrollee medical savings account.

Religious-Fraternal Benefit (RFB) Society Plans offered by RFB societies, defined in

Chapter 1 of the manual may be any of the 3 types of MA plans (CCP, PFFS, or MSA

plan), and are subject to the payment rules pertaining to the plan type.

Under Section 1859(e)(4), as implemented at 422.304(c)(3), CMS is required to adjust MA

payment rates to RFB plans to appropriate levels, taking into account “the actuarial

characteristics and experience” of RFB enrollees. This provision pre-dates implementation

of risk adjustment by CMS. In 2006 CMS implemented the third generation risk

adjustment model, the CMS-HCC model discussed in 42 CFR 50. CMS will adjust

payments to RFB society plans to account for the actuarial characteristics of their enrollees

using this model. Application of this model will appropriately adjust payments to RFB

societies for the characteristics of their RFB plan enrollees.