Code of Federal Regulations (Last Updated: May 6, 2024) |
Title 42 - Public Health |
Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
SubChapter B - Medicare Program |
Part 422 - Medicare Advantage Program |
Subpart E - Relationships With Providers |
§ 422.220 - Exclusion of payment for basic benefits furnished under a private contract.
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§ 422.220 Exclusion of services payment for basic benefits furnished under a private contract.
Anservices (other than emergency or urgently needed services as defined in § 422.2)(a) Unless otherwise authorized in paragraph (b) or (c) of this section, an MA organization may not pay, directly or indirectly, on any basis, for
(1)basic benefits furnished to a Medicare enrollee by a physician (as defined in paragraphs (1), (2), (3), and (4) of section 1861(r)
carrierof the Act) or other practitioner (as defined in section 1842(b)(18)(C) of the Act) who has filed with the Medicare
contractor an affidavit promising to furnish Medicare-covered services to Medicare beneficiaries only through private contracts under section 1802(b) of the Act with the beneficiaries.
(b) An MA organization must pay for emergency or urgently needed services furnished by a physician or practitioner described in paragraph (a) of this section who has not signed a private contract with the beneficiary.
(c) An MA organization may make payment to a physician or practitioner described in paragraph (a) of this section for services that are not basic benefits but are provided to a beneficiary as a supplemental benefit consistent with § 422.102.
[86 FR 6098, Jan. 19, 2021]