US · guidance
CMS Pub. 100-16, ch. 9, § 20
Benefit Design Requirement Waivers
MAOs are permitted to modify the cost sharing, benefit level and/or premium offered only to
employers/unions from the levels of cost sharing, benefits and premiums offered to individual
enrollees as long as the minimum required Medicare coverage levels (i.e., benefits and coverage
equivalent to Fee-For-Service (FFS) Medicare) 3 are met and as long as the modification does not
violate applicable CMS cost sharing limits for discriminatory cost sharing and mandatory
maximum out-of-pocket (MOOP) limit requirements. These requirements can be found in the
Medicare Managed Care Manual, Chapter 4 (Benefits and Beneficiary Protections), §50.1.
Also, to the extent that there are specific MA requirements concerning cost sharing or benefit
coverage requirements, these requirements apply equally to EGWPs unless explicitly waived or
modified.
History
(Rev. 111, 05-03-13, Effective: 05-03-13, Implementation: 05-03-13)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
246c03ba3609b1128e5cb88ad100ec319921b465b171e48ab13de3cda59fdc80
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