CMS Pub. 100-16, ch. mc86c17f, § 40.2

(Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05)

(42 CFR 417.456(b)) A Medicare cost plan must agree to refund all amounts incorrectly

collected from its Medicare enrollees, or from others on behalf of the enrollees, and any

other amounts due the enrollees or others on their behalf.

(42 CFR 417.456(a)) Amounts incorrectly collected means amounts collected that are

in excess of those due to:

• Deductibles;

• Coinsurances;

• Non-covered Medicare services (which are not supplemental benefits);

• Services for which Medicare is not the primary payer; or

• Supplemental benefit premiums and copays.

Amounts incorrectly collected include amounts collected when the enrollee was

believed not entitled to Medicare benefits, and the services were furnished while the

person was enrolled in the cost plan, if the enrollee is later determined, upon appeal, to

have been entitled to Medicare benefits and CMS is liable for these payments.

Other amounts due means amounts due a Medicare enrollee for services obtained

outside the Medicare cost plan if they were:

• Emergency services;

• Urgently needed services for which the Medicare cost plan has assumed financial

responsibility; or

• On appeal, found to be services the enrollee was entitled to have furnished by the

Medicare cost plan.

In general a Medicare cost plan may make payments to enrollees either in the form of

lump sum payments, premium adjustment, or both.