US · guidance
CMS Pub. 100-16, ch. mc86c16a, § 70.3.4
Cost Sharing Rules for Members
• The plan cannot vary a member’s actual out-of-pocket costs (regardless of
whether copayment or coinsurance applies) with respect to a particular category
of Part A or Part B service for direct-contracting providers.
• The plan cannot vary a member’s actual out-of-pocket costs (regardless of
whether copayment or coinsurance applies) with respect to a particular category
of Part A or Part B service for deemed providers.
• The member’s actual out-of-pocket costs (regardless of whether copayment or
coinsurance applies) with respect to a particular category of Part A or Part B
service may be higher when the member receives out-of-network services from a
deemed provider instead of in-network services from a direct-contracting
provider.
History
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
e9f1168831129e1f2a661a322c778a730e8b52f13753f3109acc8de1e4e95802
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