CMS Pub. 100-16, ch. 9, § 20.1

MAOs offering plans for individual enrollment (i.e., not employer-only plans) have the

flexibility when negotiating with employers/unions to raise cost sharing (coinsurance,

3 Sections 1852(a)(1)(A) and 1852(b) of the Act; 42 CFR 422.101

copayments and/or deductibles) for plan benefits by providing a higher benefit level and/or a

modified premium compared to what is offered for non-employer/union group members.

Example: An MAO might offer a plan to individual beneficiaries with a $10 copayment for

all physician office visits (primary care and specialist). The MAO might want to offer

employers/unions an MA plan that includes a $5 copayment for primary care physician visits

and a $20 copayment for specialist physician visits.

An MAO may take advantage of this flexibility by informing CMS of its intentions when it

submits its bid proposals and providing supporting documentation for the MA plans it

intends to offer to employer/union sponsors. In its supporting documentation to CMS, the

MAO must identify the following:

• The cost sharing amounts the MAO intends to change and the MA plan containing the

cost sharing;

• Any modification to the premium charged; and

• Any improvement in the benefit related to the changed cost sharing.

An MAO is 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 are met and the

modification does not have the effect of denying or discouraging access to covered medically-necessary health care items and services. Unlike the actuarial swapping flexibility outlined

below in §20.2, this customization can apply to Medicare-covered benefits and non-Medicare-covered benefits. Please note this waiver/modification applies only to employer/union group

sponsorship of individual MA plans.