42 C.F.R. § 417.524
Payment to HMOs or CMPs: General
(a) Basic rule. The payments that CMS makes to an HMO or CMP under this subpart and subparts O and P of this part for furnishing covered Medicare services are in place of any payment that CMS would otherwise make to a beneficiary or the HMO or CMP under sections 1814(b) and 1833(a) of the Act.
(b) Basis of payment. (1) CMS pays the HMOs or CMPs on either a reasonable cost basis or a risk basis depending on the type of contract the HMO or CMP has with CMS.
(2) In certain cases a risk HMO or CMP also receives payments on a reasonable cost basis for certain Medicare enrollees who retain nonrisk status, as provided in § 417.444, after the HMO or CMP enters into a risk contract.
Notes of Decisions
Cited in 1
case (1 in the last 5 years), 2023–2023 · leading case: Medica Ins. Co. v. Becerra (D.D.C. 2023).
Medica Ins. Co. v. Becerra (D.D.C. 2023). “§ 1395mm(h)(2); 1395x(v)(1)(A); 42 C.F.R. § 417.524 (b)(2). Under the Medicare Act, the “reasonable cost” of these services are defined in relevant part as “the cost actually incurred, excluding therefrom any part of incurred cost found to be unnecessary in the efficient…”
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