4. January 2005 Regulatory Change

18. ‘Regulations at 42 CFR § stipulate that each Medicare Advantage plan must meet the requirement to “provide coverage of, by furnishing, arranging for, or making payment for all, services that are covered by Part A and Part B of Medicare…”.  Further, Chapter 4 of the Medicare Managed Care Manual specifically states in Section 30.2 page 30, under “Prohibition of Benefits for Non-enrollees”,   that an “MAO may not offer as a benefit services furnished to a person other than the enrollee (unless Original Medicare specifically allows such services e.g. Original Medicare coverage of a living donor for medical complications arising from a kidney transplant)”.   
Susan S. Radke, Centers for Medicare & Medicaid Services
Division of Policy, Analysis, and Planning MCAG/CPC
September 18, 2014

19. “Moreover, Original Medicare Benefit Policy Manual Chapter 11 Section  states, “Instead, during the donor’s inpatient stay for the excision surgery and during any subsequent donor inpatient stays resulting from a direct complication of the organ donation, physician services are billed under Part B. They are billed in the normal manner but on the account of the recipient at 100 percent of the fee schedule.  Note that services furnished to kidney donors are covered under the account of the recipient.”
“Therefore, the MA plan must provide payment of the Original Medicare service to the organ donor and in this case, the MA plan is required to pay for the care of the complications and follow up from the donation of the organ.”
Susan S. Radke, Centers for Medicare & Medicaid Services
Division of Policy, Analysis, and Planning MCAG/CPC
September 18, 2014

21. “If any of these scenarios that you identify actually occur, please contact us so that we can address those specific situations.  Generally, the MA plan that was covering the recipient at time of the organ donation and kidney transplant is responsible for payment, even if the recipient has gone back to original Medicare or changed plans.  But, we really would need to know the specifics I each situation to make this determination.”
Susan S. Radke, Centers for Medicare & Medicaid Services
Division of Policy, Analysis, and Planning MCAG/CPC
September 18, 2014