US · guidance
CMS Pub. 100-16, ch. mc86c17c, § 40
Provider Services Furnished Directly by Cost-Based HMO/CMPs
When a provider owned or operated by the cost-based HMO/CMP, or related to the
HMO/CMP by common ownership or control (referred to here as a "plan provider"),
furnishes services directly to the HMO/CMP’s enrollees, it is subject to the same cost
finding and apportionment requirements or the prospective payment system applicable to
other providers under Medicare. These are set forth in Chapters 23 and 28 of the
Medicare Provider Reimbursement Manual (Pub. 15), Part I. An approved method of
cost finding described in that manual must be used to determine the actual cost of
covered services furnished directly by the HMO/CMP during the reporting period.
The essential difference between cost-based HMO/CMP and non-HMO/CMP (i.e.,
unrelated) providers is that a cost-based plan provider will, in effect, have two separate
reimbursement settlements with the Medicare program. It will have, one for Medicare
patients who are not enrolled in the cost-based HMO/CMP, and one for Medicare
beneficiaries who are cost-based HMO/CMP enrollees.
History
(Rev. 4, 10-01-01)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
e340192ccd8603347a4daf65f7a97b40b64c4f5c4055185eb36328a7759002e9
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