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Services furnished by an organization (or its contractors or subcontractors) to enrollees exception

Services furnished by an organization (or its contractors or subcontractors) to enrollees exception

42 CFR 411.355(c) provides that the following organizations and their health plans fall within this exception:
  • Health maintenance organizations or competitive medical plans under contract with CMS to provide services to the Medicare program;
  • Health care prepayment plans in accordance with an agreement with CMS;
  • Organizations providing services on a prepaid basis for Medicare enrollees through a demonstration project;
  • Certain qualified health maintenance organizations and coordinated care plans;
  • Certain managed care organizations contracting with a state under section 1903(m) of the Social Security Act;
  • Certain prepaid inpatient health plans or prepaid ambulance health plans contracting with states;
  • Certain health insuring organizations contracting with states; and
  • Certain entities operating under a demonstration project under various sections of the Social Security Act.
This exception allows physicians to make such referrals within these organizations, notwithstanding that the physician may have an ownership/investment interest or compensation arrangement with the organization. This exception applies only to services provided by the contractors or subcontractors of the specific organizations referenced above.
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