SubE

Medicare Plus Choice (M+C): Interim Final Rule

 Subpart E–Relationships with Providers.

422.200 Basis and scope.

This subpart is based on sections 1852(a)(1), (a)(2), (b)(2),
(c)(2)(D), (j), and (k) of the Act; section 1859(b)(2)(A) of the Act;
and the general authority under 1856(b) of the Act requiring the
establishment of standards. It sets forth the requirements and
standards for the M+C organization’s relationships with providers
including physicians, other health care professionals, institutional
providers and suppliers, under contracts or arrangements or deemed
contracts under M+C private fee-for-service plans. This subpart also
contains some requirements that apply to noncontracting providers.
[[Page 35086]]

Sec. 422.202 Participation procedures.

(a) Notice and appeal rights. An M+C
organization that operates a coordinated care plan or network MSA
plan must provide for the participation of individual health care
professionals, and the management and members of groups of health
care professionals, through reasonable procedures that include the
following: (1) Written notice of rules of participation such as terms
for payment, utilization review, quality improvement programs,
credentialing, data reporting, confidentiality, guidelines or
criteria for the furnishing of particular services, and other rules
related to administrative policy. (2) Written notice of material
changes in participation rules before the changes are put into
effect. (3) Written notice of participation decisions that are
adverse to health care professionals. (4) A process for appealing
adverse decisions, including the right of physicians and other health
care professionals to present information and their views on the
decision. In the case of a termination of a provider contract by the
M+C organization, this process must conform to the rules in Sec.
422.204(c).

(b) Consultation. The M+C
organization must consult with the physicians, and other health care
professionals who have agreed to provide services under an M+C plan
offered by the organization, regarding the organization’s medical
policy, quality assurance program, and medical management procedures
and ensure that the following standards are met: (1) Practice
guidelines and utilization management guidelines– (i) Are based on
reasonable medical evidence or a consensus of health care
professionals in the particular field; (ii) Consider the needs of the
enrolled population; (iii) Are developed in consultation with
contracting health care professionals; and (iv) Are reviewed and
updated periodically. (2) The guidelines are communicated to
providers and, as appropriate, to enrollees. (3) Decisions with
respect to utilization management, enrollee education, coverage of
services, and other areas in which the guidelines apply are
consistent with the guidelines.

(c) An M+C organization that operates an M+C
plan through subcontracted physician groups or other
subcontracted networks of health care professionals must provide that
the participation procedures in this section apply equally to
physicians and other health care professionals within those
subcontracted groups.

Sec. 422.204 Provider credentialing and provider rights.

(a) Basic requirements. An M+C
organization must follow a documented process with respect to
providers and suppliers who have signed contracts or participation
agreements that– (1) For providers (other than physicians and other
health care professionals) requires determination, and
redetermination at specified intervals, that each provider– (i)
Licensed to operate in the State, and in compliance with any other
applicable State or Federal requirements; and (ii) Reviewed and
approved by an accrediting body, or meets the standards established
by the organization itself; (2) For physicians and other health care
professionals, including members of physician groups, covers– (i)
Initial credentialing that includes written application, verification
of licensure and other information from primary sources, disciplinary
status, eligibility for payment under Medicare, and site visits as
appropriate. The application must be signed and dated and include an
attestation by the applicant of the correctness and completeness of
the application and other information submitted in support of the
application; (ii) Recredentialing at least every 2 years that updates
information obtained during initial credentialing and considers
performance indicators such as those collected through quality
assurance programs, utilization management systems, handling of
grievances and appeals, enrollee satisfaction surveys, and other plan
activities, and that includes an attestation of the correctness and
completeness of the new information; and (iii) A process for
receiving advice from contracting health care professionals with
respect to criteria for credentialing and recredentialing; and (iv)
Requiring that, to the extent applicable, the requirements in
paragraphs (a)(2)(i) and (a)(2)(iii) of this section are satisfied;
and (3)(i) Specify that basic benefits must be provided through, or
payments must be made to, providers that meet applicable requirements
of title XVIII and part A of title XI of the Act. In the case of
providers meeting the definition of “provider of services” in section
1861(u), basic benefits may only be provided through such providers
if they have a provider agreement with HCFA permitting them to
provide services under original Medicare. (ii) Ensures compliance
with the requirements at Sec. 422.752(a)(8) that prohibit employment
or contracts with individuals (or with an entity that employs or
contracts with such an individual) excluded from participation under
Medicare and with the requirements at Sec. 422.220 regarding
physicians and practitioners who opt out of Medicare.

(b) Discrimination prohibited–(1)
General rule. An M+C organization may not discriminate, in terms of
participation, reimbursement, or indemnification, against any health
care professional who is acting within the scope of his or her
license or certification under State law, solely on the basis of the
license or certification. (2) Construction. The prohibition in
paragraph (b)(1) of this section does not preclude any of the
following by the M+C organization: (i) Refusal to grant participation
to health care professionals in excess of the number necessary to
meet the needs of the plan’s enrollees (except for M+C
private-fee-for-service plans, which may not refuse to contract on
this basis). (ii) Use of different reimbursement amounts for
different specialties. (iii) Implementation of measures designed to
maintain quality and control costs consistent with its
responsibilities.

(c) Denial, suspension, or termination of
contract. The requirements in this paragraph (c) apply to an
M+C organization that operates a coordinated care plan or network MSA
plan providing benefits through contracting providers. (1) Notice to
health care professional. An M+C organization that denies, suspends,
or terminates an agreement under which the health care professional
provides services to M+C plan enrollees must give the affected
individual written notice of the following: (i) The reasons for the
action. (ii) The standards and the profiling data the organization
used to evaluate the health care professional. (iii) The numbers and
mix of health care professionals the organization needs. (iv) The
affected health care professional’s right to appeal the action and
the process and timing for requesting a hearing. (2) Composition of
hearing panel. The M+C organization must ensure that the majority of
the hearing panel members are peers of the affected health care
professional. [[Page 35087]] (3) Notice to licensing or disciplinary
bodies. An M+C organization that suspends or terminates a contract
with a health care professional because of deficiencies in the
quality of care must give written notice of that action to licensing
or disciplinary bodies or to other appropriate authorities. (4)
Timeframes. An M+C organization and a contracting provider must
provide at least 60 days written notice to each other before
terminating the contract without cause.

Sec. 422.206 Interference with health care professionals’
advice to enrollees prohibited.

(a) General rule. (1) An M+C
organization may not prohibit or otherwise restrict a health care
professional, acting within the lawful scope of practice, from
advising, or advocating on behalf of, an individual who is a patient
and enrolled under an M+C plan about– (i) The patient’s health
status, medical care, or treatment options (including any alternative
treatments that may be self-administered), including the provision of
sufficient information to the individual to provide an opportunity to
decide among all relevant treatment options; (ii) The risks,
benefits, and consequences of treatment or non- treatment; or (iii)
The opportunity for the individual to refuse treatment and to express
preferences about future treatment decisions. (2) Health care
professionals must provide information regarding treatment options in
a culturally-competent manner, including the option of no treatment.
Health care professionals must ensure that individuals with
disabilities have effective communications with participants
throughout the health system in making decisions regarding treatment
options.

(b) Conscience protection. The
general rule in paragraph (a) of this section does not require the
M+C plan to cover, furnish, or pay for a particular counseling or
referral service if the M+C organization that offers the plan– (1)
Objects to the provision of that service on moral or religious
grounds; and (2) Through appropriate written means, makes available
information on these policies as follows: (i) To HCFA, with its
application for a Medicare contract, or within 10 days of submitting
its ACR proposal, as appropriate. (ii) To prospective enrollees,
before or during enrollment. (iii) With respect to current enrollees,
the organization is eligible for the exception provided in paragraph
(a)(1) of this section if it provides notice within 90 days after
adopting the policy at issue; however, under Sec. 422.111(d), notice
of such a change must be given in advance.

(c) Construction. Nothing in
paragraph (b) of this section may be construed to affect disclosure
requirements under State law or under the Employee Retirement Income
Security Act of 1974.

(d) Sanctions. An M+C organization
that violates the prohibition of paragraph (a) of this section or the
conditions in paragraph (b) of this section is subject to
intermediate sanctions under subpart O of this
part.

Sec. 422.208 Physician incentive plans: requirements and
limitations.

(a) Definitions. In this subpart, the
following definitions apply:

• Bonus means a payment made to a physician or physician group
  beyond any salary, fee-for-service payments, capitation, or
  returned withhold.

• Capitation means a set dollar payment per patient per unit of
  time (usually per month) paid to a physician or physician group to
  cover a specified set of services and administrative costs without
  regard to the actual number of services provided. The services
  covered may include the physician’s own services, referral
  services, or all medical services.

• Physician group means a partnership, association, corporation,
  individual practice association, or other group of physicians that
  distributes income from the practice among members. An individual
  practice association is defined as a physician group for this
  section only if it is composed of individual physicians and has no
  subcontracts with physician groups.

• Physician incentive plan means any compensation arrangement to
  pay a physician or physician group that may directly or indirectly
  have the effect of reducing or limiting the services provided to
  any plan enrollee.

• Potential payments means the maximum payments possible to
  physicians or physician groups including payments for services
  they furnish directly, and additional payments based on use and
  costs of referral services, such as withholds, bonuses,
  capitation, or any other compensation to the physician or
  physician group. Bonuses and other compensation that are not based
  on use of referrals, such as quality of care furnished, patient
  satisfaction or committee participation, are not considered
  payments in the determination of substantial financial risk.

• Referral services means any specialty, inpatient, outpatient,
  or laboratory services that a physician or physician group orders
  or arranges, but does not furnish directly.

• Risk threshold means the maximum risk, if the risk is based on
  referral services, to which a physician or physician group may be
  exposed under a physician incentive plan without being at
  substantial financial risk. This is set at 25 percent risk.

• Substantial financial risk, for purposes of this section,
  means risk for referral services that exceeds the risk threshold.

• Withhold means a percentage of payments or set dollar amounts
  deducted from a physician’s service fee, capitation, or salary
  payment, and that may or may not be returned to the physician,
  depending on specific predetermined factors.

(b) Applicability. The requirements
in this section apply to an M+C organization and any of its
subcontracting arrangements that utilize a physician incentive plan
in their payment arrangements with individual physicians or physician
groups. Subcontracting arrangements may include an intermediate
entity, which includes but is not limited to, an individual practice
association that contracts with one or more physician groups or any
other organized group such as those specified in Sec. 422.4.

(c) Basic requirements. Any physician
incentive plan operated by an M+C organization must meet the
following requirements: (1) The M+C organization makes no specific
payment, directly or indirectly, to a physician or physician group as
an inducement to reduce or limit medically necessary services
furnished to any particular enrollee. Indirect payments may include
offerings of monetary value (such as stock options or waivers of
debt) measured in the present or future. (2) If the physician
incentive plan places a physician or physician group at substantial
financial risk (as determined under paragraph (d) of this section)
for services that the physician or physician group does not furnish
itself, the M+C organization provides aggregate or per-patient
stop-loss protection in accordance with paragraph (f) of this
section, and conducts periodic surveys in accordance with paragraph
(g) of this section. (3) For all physician incentive plans, the M+C
organization provides to HCFA the information specified in Sec.
422.210.

(d) Determination of substantial financial
risk–(1) Basis. Substantial financial risk occurs when risk
is based on the use or costs of referral services, [[Page 35088]] and
that risk exceeds the risk threshold. Payments based on other
factors, such as quality of care furnished, are not considered in
this determination. (2) Risk threshold. The risk threshold is 25
percent of potential payments. (3) Arrangements that cause
substantial financial risk. The following incentive arrangements
cause substantial financial risk within the meaning of this section,
if the physician’s or physician group’s patient panel size is not
greater than 25,000 patients, as shown in the table at paragraph
(f)(2)(iii) of this section: (i) Withholds greater than 25 percent of
potential payments. (ii) Withholds less than 25 percent of potential
payments if the physician or physician group is potentially liable
for amounts exceeding 25 percent of potential payments. (iii) Bonuses
that are greater than 33 percent of potential payments minus the
bonus. (iv) Withholds plus bonuses if the withholds plus bonuses
equal more than 25 percent of potential payments. The threshold bonus
percentage for a particular withhold percentage may be calculated
using the formula–Withhold % = -0.75 (Bonus %) +25%. (v) Capitation
arrangements, if– (A) The difference between the maximum potential
payments and the minimum potential payments is more than 25 percent
of the maximum potential payments; (B) The maximum and minimum
potential payments are not clearly explained in the contract with the
physician or physician group. (vi) Any other incentive arrangements
that have the potential to hold a physician or physician group liable
for more than 25 percent of potential payments.

(e) An M+C fee-for-service plan may not
operate a physician incentive plan.

(f) Stop-loss protection
requirements. (1) Basic rule. The M+C organization must assure
that all physicians and physician groups at substantial financial
risk have either aggregate or per-patient stop- loss protection in
accordance with the following requirements: (2) Specific
requirements. (i) Aggregate stop-loss protection must cover 90
percent of the costs of referral services that exceed 25 percent of
potential payments. (ii) For per-patient stop-loss protection if the
stop-loss protection provided is on a per-patient basis, the
stop-loss limit (deductible) per patient must be determined based on
the size of the patient panel and may be a combined policy or consist
of separate policies for professional services and institutional
services. In determining patient panel size, the patients may be
pooled in accordance with paragraph (g) of this section. (iii)
Stop-loss protection must cover 90 percent of the costs of referral
services that exceed the per patient deductible limit. The
per-patient stop-loss deductible limits are as follows:

Panel size	Single combined deductible	Separate institutional deductible	Separate professional deductible
1-1000	$6000	$10,000	$3000
1001-5000	30,000	40,000	10,000
5001-8000	40,000	60,000	15,000
8001-10,000	75,000	100,000	20,000
10,001-25,000	150,000	200,000	25,000
25,000+	*	*	*

* None.

(g) Pooling of patients. Any entity
that meets the pooling conditions of this section may pool
commercial, Medicare, and Medicaid enrollees or the enrollees of
several M+C organizations with which a physician or physician group
has contracts. The conditions for pooling are as follows: (1) It is
otherwise consistent with the relevant contracts governing the
compensation arrangements for the physician or physician group. (2)
The physician or physician group is at risk for referral services
with respect to each of the categories of patients being pooled. (3)
The terms of the compensation arrangements permit the physician or
physician group to spread the risk across the categories of patients
being pooled. (4) The distribution of payments to physicians from the
risk pool is not calculated separately by patient category. (5) The
terms of the risk borne by the physician or physician group are
comparable for all categories of patients being pooled.

(h) Periodic surveys of current and former
enrollees. An M+C organization must conduct periodic surveys
of current and former enrollees where substantial financial risk
exists. These periodic surveys must– (1) Include either a sample of,
or all, current Medicare/Medicaid enrollees in the M+C organization
and individuals disenrolled in the past 12 months for reasons other
than– (i) The loss of Medicare or Medicaid eligibility; (ii)
Relocation outside the M+C organization’s service area; (iii) For
failure to pay premiums or other charges; (iv) For abusive behavior;
and (v) Retroactive disenrollment. (2) Be designed, implemented, and
analyzed in accordance with commonly accepted principles of survey
design and statistical analysis; (3) Measure the degree of
enrollees/disenrollees’ satisfaction with the quality of the services
provided and the degree to which the enrollees/disenrollees have or
had access to the services provided under the M+C organization; and
(4) Be conducted no later than 1 year after the effective date of the
M+C organization’s contract and at least annually thereafter. (i)
Sanctions. An M+C organization that fails to comply with the
requirements of this section is subject to intermediate sanctions
under subpart O of this part.

Sec. 422.210 Disclosure of physician incentive plans

(a) Disclosure to HCFA–(1) Basic
requirement. Each M+C organization must provide to HCFA descriptive
information about its physician incentive plan in sufficient detail
to enable HCFA to determine whether that plan complies with the
requirements of Sec. 422.208. Reporting should be on the HCFA PIP
Disclosure Form (OMB No. 0938-0700). (2) Content. The information
must include at least the following: (i) Whether services not
furnished by the physician or physician group are covered by the
incentive plan. (ii) The type or types of incentive arrangements,
such as, withholds, bonus, capitation. [[Page 35089]] (iii) The
percent of any withhold or bonus the plan uses. (iv) Assurance that
the physicians or physician group has adequate stop-loss protection,
and the amount and type of stop-loss protection. (v) The patient
panel size and, if the plan uses pooling, the pooling method. (vi) If
the M+C organization is required to conduct enrollee surveys, a
summary of the survey results. (3) When disclosure must be made to
HCFA. An M+C organization must disclose annually to HCFA the
physician incentive arrangements that are effective at the start of
each year. In addition, HCFA does not approve an M+C organization’s
application for a contract unless the M+C organization discloses the
physician incentive arrangements effective for that contract.

(b) Disclosure to Medicare
beneficiaries–Basic requirement. An M+C organization must
provide the following information to any Medicare beneficiary who
requests it: (1) Whether the M+C organization uses a physician
incentive plan that affects the use of referral services. (2) The
type of incentive arrangement. (3) Whether stop-loss protection is
provided. (4) If the M+C organization was required to conduct a
survey, a summary of the survey results.

Sec. 422.212 Limitations on provider indemnification.

An M+C organization may not contract or otherwise provide,
directly or indirectly, for any of the following individuals,
organizations, or entities to indemnify the organization against any
civil liability for damage caused to an enrollee as a result of the
M+C organization’s denial of medically necessary care:

(a) A physician or health care professional.

(b) Provider of services.

(c) Other entity providing health care services.

(d) Group of such professionals, providers, or
entities.

Sec. 422.214 Special rules for services furnished by
noncontract providers.

(a) Services furnished to enrollees of
coordinated care plans by providers. (1) Any provider (other
than a provider of services as defined in section 1861(u) of the Act)
that does not have in effect a contract establishing payment amounts
for services furnished to a beneficiary enrolled in an M+C
coordinated care plan must accept, as payment in full, the amounts
that the provider could collect if the beneficiary were enrolled in
original Medicare. (2) Any statutory provisions (including penalty
provisions) that apply to payment for services furnished to a
beneficiary not enrolled in an M+C plan also apply to the payment
described in paragraph (a)(1) of this section.

(b) Services furnished by providers of
service. Any provider of services as defined in section
1861(u) of the Act that does not have in effect a contract
establishing payment amounts for services furnished to a beneficiary
enrolled in an M+C coordinated care plan must accept as payment in
full the amounts (less any payments under Secs. 412.105(g) and
413.86(d)) that it could collect if the beneficiary were enrolled in
original Medicare.

Sec. 422.216 Special rules for M+C private fee-for-service
plans.

(a) Payment to providers–(1) Payment
rate. (i) The M+C organization must establish uniform payment rates
for items and services that apply to all contracting providers,
regardless of whether the contract is signed or deemed under
paragraph (f) of this section. (ii) Contracting providers must be
reimbursed on a fee-for-service basis. (iii) The M+C organization
must make information on its payment rates available to providers
that furnish services that may be covered under the M+C private
fee-for-service plan. (2) Payment to contract providers. For each
service, the M+C organization pays a contract provider (including one
deemed to have a contract) an amount that is equal to the payment
rate under paragraph (a)(1) of this section minus any applicable
cost-sharing. (3) Noncontract providers. The organization pays for
services of noncontract providers in accordance with Sec.
422.100(b)(2). (4) Service furnished by providers of service. Any
provider of services as defined in section 1861(u) of the Act that
does not have in effect a contract establishing payment mounts for
services furnished to a beneficiary enrolled in an M+C private
fee-for-service plan must accept as payment in full the amounts (less
any payments under Secs. 412.109(g) and 413.86(d) of this chapter)
that it could collect if the beneficiary were enrolled in original
Medicare.

(b) Charges to enrollees–(1)
Contract providers. (i) Contract providers and “deemed” contract
providers may charge enrollees no more than the cost-sharing and,
subject to the limit in paragraph (b)(1)(ii) of this section, balance
billing amounts that are permitted under the plan, and these amounts
must be the same for “deemed” contract providers as for those that
have signed contracts in effect. (ii) The organization may permit
balance billing no greater than 15 percent of the payment rate
established under paragraph (a)(1) of this section. (iii) The M+C
organization must specify the amount of cost-sharing and balance
billing in its contracts with providers and these amounts must be the
same for “deemed” contract providers as for those that have signed
contracts in effect. (iv) The M+C organization is subject to
intermediate sanctions under Sec. 422.752(a)(7), under the rules in
subpart O of this part, if it fails to enforce the limit specified in
paragraph (b)(1)(i) of this section. (2) Noncontract providers. A
noncontract provider may not collect from an enrollee more than the
cost-sharing established by the M+C private fee-for-service plan as
specified in Sec. 422.308(b).

(c) Enforcement of limit--(1)
Contract providers. An M+C organization that offers an M+C
fee-for-service plan must enforce the limit specified in paragraph
(b)(1) of this section. (2) Noncontract providers. An M+C
organization that offers an M+C private fee-for-service plan must
monitor the amount collected by noncontract providers to ensure that
those amounts do not exceed the amounts permitted to be collected
under paragraph (b)(2) of this section. The M+C organization must
develop and document violations specified in instructions and must
forward documented cases to HCFA.

(d) Information on enrollee
liability–(1) General information. An M+C organization that
offers an M+C fee-for-service plan must provide to plan enrollees,
for each claim filed by the enrollee or the provider that furnished
the service, an appropriate explanation of benefits. The explanation
must include a clear statement of the enrollee’s liability for
deductibles, coinsurance, copayment, and balance billing. (2) Advance
notice for hospital services. In its terms and conditions of payment
to hospitals, the M+C organization must require the hospital, if it
imposes balance billing, to provide to the enrollee, before
furnishing any services for which balance billing could amount to not
less than $500– (i) Notice that balance billing is permitted for
those services; (ii) A good faith estimate of the likely amount of
balance billing, based on the enrollees presenting condition; and
[[Page 35090]] (iii) The amount of any deductible, coinsurance, and
copayment that may be due in addition to the balance billing amount.

(e) Coverage determinations. The M+C
organization must make coverage determinations in accordance with
subpart M of this part.

(f) Rules describing deemed contract
providers. Any provider furnishing health services to an
enrollee in an M+C private fee-for- service plan, and who has not
previously entered into a contract or agreement to furnish services
under the plan, is treated as having a contract in effect and is
subject to the limitations of this section that apply to contract
providers if the following conditions are met: (1) The services are
covered under the plan and are furnished– (i) To an enrollee of an
M+C fee-for-service plan; and (ii) Provided by a provider including a
provider of services (as defined in section 1861(u) of the Act) that
does not have in effect a signed contract with the M+C organization.
(2) Before furnishing the services, the provider– (i) Was informed
of the individual’s enrollment in the plan; and (ii) Was informed (or
given a reasonable opportunity to obtain information) about the terms
and conditions of payment under the plan, including the information
described in Sec. 422.202(a)(1). (3) The information was provided in
a manner that was reasonably designed to effect informed agreement
and met the requirements of paragraphs (g) and (h) of this section.

(g) Enrollment information.
Enrollment information was provided by one of the following methods
or a similar method: (1) Presentation of an enrollment card or other
document attesting to enrollment. (2) Notice of enrollment from HCFA,
a Medicare intermediary or carrier, or the M+C organization itself.

(h) Information on payment terms and
conditions. Information on payment terms and conditions was
made available through either of the following methods: (1) The M+C
organization used postal service, electronic mail, FAX, or telephone
to communicate the information to one of the following: (i) The
provider. (ii) The employer or billing agent of the provider. (iii) A
partnership of which the provider is a member. (iv) Any party to
which the provider makes assignment or reassigns benefits. (2) The
M+C organization has in effect a procedure under which– (i) Any
provider furnishing services to an enrollee in an M+C private
fee-for-service plan, and who has not previously entered into a
contract or agreement to furnish services under the plan, can receive
instructions on how to request the payment information; (ii) The
organization responds to the request before the entity furnishes the
service; and (iii) The information the organization provides includes
the following: (A) Billing procedures. (B) The amount the
organization will pay towards the service. (C) The amount the
provider is permitted to collect from the enrollee. (D) The
information described in Sec. 422.202(a)(1). (3) Announcements in
newspapers, journals, or magazines or on radio or television are not
considered communication of the terms and conditions of payment.

(i) Provider credentialing
requirements. Contracts with providers must provide that, in
order to be paid to provide services to plan enrollees, providers
must meet the requirements specified in Sec. 422.204(a)(1) and
(a)(1)(iii).

Sec. 422.220 Exclusion of services furnished under a private
contract.

An M+C organization may not pay, directly or indirectly, on any
basis, for services (other than emergency or urgently needed services
as defined in Sec. 422.2) furnished to a Medicare enrollee by a
physician (as defined in section 1861(r)(1) of the Act) or other
practitioner (as defined in section 1842(b)(18)(C) of the Act) who
has filed with the Medicare carrier 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. An M+C organization must pay for emergency or urgently
needed services furnished by a physician or practitioner who has not
signed a private contract with the beneficiary.

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