CMS Pub. 100-16, ch. 8, § 40.4

Determinations and Legislative Changes in Benefits

(Rev. 89; Issued: 11-02-07; Effective/Implementation: 11-02-07)

See Chapter 4, 42 CFR 90 for definitions and guidance on National Coverage

Determinations (NCDs) and legislative change in benefits (LCBs). As set forth in 42 CFR

422.308(g), if CMS determines and announces that an NCD or LCB meets the one of the

criteria for “significant cost,” an MA organization is not required to assume risk for the

costs of that item or service until the contract year for which MA capitation rates are

appropriately adjusted to take into account the cost of the NCD or LCB.

The term “significant cost,” as it relates to a particular NCD or legislative change in

benefits, means either of the following:

1. The average cost of furnishing a single service exceeds a cost threshold that for

calendar years 1998 and 1999 is $100,000, and for calendar year 2000 and

subsequent calendar years is the preceding year’s dollar threshold adjusted to reflect

the national per capita growth percentage (described at 42 CFR 422.308(a)); or

2. The estimated cost of Medicare services furnished as a result of a particular NCD or

LCB represents at least 0.1 percent of the national average per capita costs.