C.F.R. » Title 42 » 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

42 C.F.R. § 422.214

Special rules for services furnished by noncontract providers

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(a) Services furnished by non-section 1861(u) 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 MA coordinated care plan, an MSA plan, or an MA private fee-for-service 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 MA plan also apply to the payment described in paragraph (a)(1) of this section.

(b) Services furnished by section 1861(u) 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 MA coordinated care plan, an MSA plan, or an MA private fee-for-service plan must accept, as payment in full, the amounts (less any payments under §§ 412.105(g) and 413.76 of this chapter) that it could collect if the beneficiary were enrolled in original Medicare. (Section 412.105(g) concerns indirect medical education payment to hospitals for managed care enrollees. Section 413.76 concerns calculating payment for direct medical education costs.)

(c) Deemed request for Medicare payment rate. A noncontract section 1861(u) of the Act provider of services that furnishes services to MA enrollees and submits the same information that it would submit for payment under Original Medicare is deemed to be seeking to be paid the amount it would be paid under Original Medicare unless the provider expressly notifies the MA organization in writing that it is billing an amount less than such amount.

(d) Regional PPO payments in non-network areas. An MA Regional PPO must pay non-contract providers the Original Medicare payment rate in those portions of its service area where it is providing access to services by non-network means under § 422.111(b)(3)(ii) of this part.

[63 FR 35085, June 26, 1998, as amended at 65 FR 40325, June 29, 2000; 70 FR 4724, Jan. 28, 2005; 70 FR 47490, Aug. 12, 2005; 76 FR 21564, Apr. 15, 2011]
Notes of Decisions
Cited in 26 cases (7 in the last 5 years), 2004–2025 · leading case: New York City Health & Hospitals Corp. v. Wellcare of New York, Inc., 801 F. Supp. 2d 126 (S.D.N.Y. 2011).
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New York City Health & Hospitals Corp. v. Wellcare of New York, Inc., 801 F. Supp. 2d 126 (S.D.N.Y. 2011). · cites it 5× “63 *138 And because the above-quoted regulation is the only relevant law or regulation incorporated into WellCare’s contract with CMS, HHC’s breach of contract claim boils down to an effort to enforce that regulation — 42 C.F.R. § 422.214 (a)(1). The Supreme Court recently…”
Tenet HealthSystem GB, Inc. v. Care Improvement Plus South Cent. Ins. Co., 875 F.3d 584 (11th Cir. 2017). · cites it 2× “Thus, the only viable claim the Hospitals can pursue is their right to recover the,same reimbursements that the enroliees were entitled to receive under the Medicare Act, and that claim is subject to the Act’s administrative exhaustion requirement.”
Ohio State Chiropractic Ass'n v. Humana Health Plan Inc., 647 F. App'x 619 (6th Cir. 2016). “” 42 C.F.R. § 422.214 (a)(1). That brings us to this case.”
Global Rescue Jets, LLC v. Kaiser Found. Health Plan, 30 F.4th 905 (9th Cir. 2022). “§ 1395w-22(k)(1); 42 C.F.R. § 422.214 (a)(1). B The two patients at the center of this case were enrolled in Medicare Advantage plans offered by Kaiser.”
Christus Health Gulf Coast v. Aetna, Inc., 237 S.W.3d 338 (Tex. 2007). “42 C.F.R. § 422.214 (a). Contracts between Medicare Advantage organizations or their delegates and downstream providers are freely negotiated, with very few exceptions.”
Allina Health Servs. v. Sebelius, 756 F. Supp. 2d 61 (D.D.C. 2010). “See 42 C.F.R. § 422.214 . CMS does, however, make information available so that hospitals and Medicare Advantage plans can estimate what Medicare Part A would have paid for a particular service.”
Caris MPI v. UnitedHealthcare, 108 F.4th 340 (5th Cir. 2024). “” 42 C.F.R. § 422.214 (a)(1) (emphasis added).”
Prime Healthcare Huntington Beach, LLC v. Scan Health Plan, 210 F. Supp. 3d 1225 (C.D. Cal. 2016). “See 42 C.F.R. § 422.214 (a) (payments limited to what “the provider would collect if *1228 the beneficiary were originally enrolled in Medicare”).”
Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co., 362 F. Supp. 3d 1217 (M.D. Fla. 2019). “42 C.F.R. § 422.214 (a)(1). 2 *1220 Beginning in December 2017, Plaintiff filed a series of cases against Defendant in small claims court, alleging that it provided medical treatment to patients, submitted claims for reimbursement of its charges for those services, and Defendant…”
Shalaby v. Heritage Physician Network, 364 F. Supp. 3d 693 (S.D. Tex. 2019). “11 at 6 [hereinafter Response ]; see 42 C.F.R. §§ 422.214 , 422.520(b)(1). Response , supra note 4, at 6; see 42 U.”
Tenet Healthsystem GB, Inc. v. Care Improvement Plus South Cent. Ins., 162 F. Supp. 3d 1307 (N.D. Ga. 2016). · cites it 2× “” 42 C.F.R. § 422.214 (a). The Medicare Act further provides that where the MA organization is made a secondary payer, as defined by 42 U.”
Doctors Med. Ctr. of Modesto, Inc. v. Kaiser Found. Health Plan, Inc., 989 F. Supp. 2d 1009 (E.D. Cal. 2013). “” 42 C.F.R. § 422.214 (a). The Medicare Act further provides that where the MA organization is made a secondary payer, as defined by 42 U.”
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— 42 C.F.R. § 422.214(b) — 2 cases
St. Charles Par. Hosp. Serv. Dist. No. 1 v. Ochsner Health Plan, Inc., 874 So. 2d 885 (La. Ct. App. 2004).
Dignity Health v. Local Initiative Health Care Auth. etc. (Cal. Ct. App. 2020).
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