US · guidance
CMS Pub. 100-16, ch. mc86c17f, § 10.8
Cap On Beneficiary Monetary Responsibility
(Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05)
(Chapter 4, §10.4 of the Medicare Managed Care Manual): A Medicare cost plan
enrollee should never pay more than the plan required cost sharing – coinsurance,
deductibles and copays. This cap on beneficiary liability holds even:
• If a provider or delegated provider declares insolvency resulting in a plan loss;
• If a non-contracted provider which provided services to the enrollee, for emergent
or urgent care is entitled to balanced billing; and
• This cap on beneficiary liability prohibits a plan from requiring a beneficiary to
first pay a contracted provider, except for copayments, and then receive
reimbursement from the Medicare cost organization.
History
(Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
c78a8993a6ce8e294f894313467553ad58639667edba417a343abc049d36e189
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