CMS Pub. 100-16, ch. mc86c16a, § 80.2

Deemed and Direct-Contracting Providers

(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11)

42 CFR 422.216(b)(1)(ii)

In addition to the Original Medicare balance billing rules described in section 80.1, there

is a special rule that permits a PFFS plan to allow deemed and direct-contracting

providers to charge the member up to 15% of the PFFS plan’s total payment rate for a

service, in addition to the plan-allowed member cost sharing. However, this special PFFS

balance billing is only permitted if it is explicitly stated in the plan’s terms and conditions

of payment for deemed providers or in the signed contract or agreement between the plan

and the direct-contracting providers. Providers are not permitted to balance bill a member

who is also enrolled in a State Medicaid program, and as a result, the member is held

harmless from Medicare cost sharing.

If a PFFS plan prohibits this special balance billing, then the deemed or direct-contracting

providers may only collect the plan-allowed cost sharing from the member and may not

otherwise charge or bill members.