US · guidance
CMS Pub. 100-16, ch. mc86c17f, § 50
Out-of-Area, Out-of-Network and Extended Absence
(Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05)
Services obtained from non-network providers (when not referred) are covered under the
Fee-For-Service program (and thus subject to Medicare Fee-For-Service coinsurance and
deductible requirements), unless they are emergency or urgently needed services. For
emergency or urgently needed services the Medicare cost plan is liable for
reimbursement and the contracted member cost sharing applies. Emergency and urgently
needed services are defined in §10.2 of this subpart.
As discussed in further detail in the enrollment section of this chapter Medicare cost
plans must disenroll an individual if that individual has permanently moved from the
Medicare cost plan’s geographic area. An uninterrupted absence of 90 days is deemed to
be a permanent move and the individual must be disenrolled unless the Medicare cost
plan offers an extended absence option (42 CFR 417.460).
A Medicare cost plan that chooses to offer an extended absence option may retain
members who temporarily (more than 90 days but less than one year) leave the
geographic area but remain in the United States either:
• By paying for all covered services for such members based on mutually agreeable
restrictions; or
• By providing services through an affiliated organization (42 CFR 417.460(f)(2)).
(42 CFR 417.460(f)(2)(ii)-(iii)) A Medicare cost plan that chooses to exercise this
exception must make the option available to all Medicare enrollees who are absent for an
extended period from their geographic areas. However, a Medicare cost plan may limit
this option to enrollees who go to a geographic area served by an affiliated Medicare cost
plan.
When a Medicare cost plan offers an extended absence option it must provide all Part A
and Part B services; however, non-Part D supplemental benefits may be discontinued on
leaving the geographic area as long as the member is not required to continue paying the
premium or portion of a premium that corresponds to these services.
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
8e5b9ddcf5a794ee4bc98c6bd2f813590703737d5f9faa9b700e400d1d6862be
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