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(A) In general
Except as provided in section 1395w–28(b)(3) of this title for MSA plans and except as provided in paragraph (6) for MA regional plans, each Medicare+Choice plan shall provide to members enrolled under this part, through providers and other persons that meet the applicable requirements of this subchapter and part A of subchapter XI, benefits under the original medicare fee-for-service program option (and, for plan years before 2006, additional benefits required under section 1395w–24(f)(1)(A) of this title ).
(i) In general For purposes of this part, the term “benefits under the original medicare fee-for-service program option” means, subject to subsection (m), those items and services (other than hospice care or coverage for organ acquisitions for kidney transplants, including as covered under section 1395rr(d) of this title ) for which benefits are available under parts A and B to individuals entitled to benefits under part A and enrolled under part B, with cost-sharing for those services as required under parts A and B or, subject to clause (iii), an actuarially equivalent level of cost-sharing as determined in this part.
(ii) Special rule for regional plans In the case of an MA regional plan in determining an actuarially equivalent level of cost-sharing with respect to benefits under the original medicare fee-for-service program option, there shall only be taken into account, with respect to the application of section 1395w–27a(b)(2) of this title , such expenses only with respect to subparagraph (A) of such section.
(iii) Limitation on variation of cost sharing for certain benefits Subject to clause (v), cost-sharing for services described in clause (iv) shall not exceed the cost-sharing required for those services under parts A and B.
(iv) Services described The following services are described in this clause: (I) Chemotherapy administration services. (II) Renal dialysis services (as defined in section 1395rr(b)(14)(B) of this title ). (III) Skilled nursing care. (IV) Clinical diagnostic laboratory test administered during any portion of the emergency period defined in paragraph (1)(B) of section 1320b–5(g) of this title beginning on or after March 18, 2020 , for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19 and the administration of such test. (V) Specified COVID–19 testing-related services (as described in section 1395 l (cc)(1) of this title) for which payment would be payable under a specified outpatient payment provision described in section 1395 l (cc)(2) of this title. (VI) A COVID–19 vaccine and its administration described in section 1395x(s)(10)(A) of this title . (VII) A drug or biological product that is a selected drug (as referred to in section 1320f–1(c) of this title ). (VIII) Such other services that the Secretary determines appropriate (including services that the Secretary determines require a high level of predictability and transparency for beneficiaries).
(v) Exception In the case of services described in clause (iv), other than subclauses (IV), (V), and (VI) of such clause, for which there is no cost-sharing required under parts A and B, cost-sharing may be required for those services in accordance with clause (i).
(vi) Prohibition of application of certain requirements for COVID–19 testing In the case of a product or service described in subclause (IV) or (V), respectively, of clause (iv) that is administered or furnished during any portion of the emergency period described in such subclause beginning on or after March 18, 2020 , an MA plan may not impose any prior authorization or other utilization management requirements with respect to the coverage of such a product or service under such plan.
For purposes of this part, the term “benefits under the original medicare fee-for-service program option” means, subject to subsection (m), those items and services (other than hospice care or coverage for organ acquisitions for kidney transplants, including as covered under section 1395rr(d) of this title ) for which benefits are available under parts A and B to individuals entitled to benefits under part A and enrolled under part B, with cost-sharing for those services as required under parts A and B or, subject to clause (iii), an actuarially equivalent level of cost-sharing as determined in this part.
In the case of an MA regional plan in determining an actuarially equivalent level of cost-sharing with respect to benefits under the original medicare fee-for-service program option, there shall only be taken into account, with respect to the application of section 1395w–27a(b)(2) of this title , such expenses only with respect to subparagraph (A) of such section.
Subject to clause (v), cost-sharing for services described in clause (iv) shall not exceed the cost-sharing required for those services under parts A and B.
The following services are described in this clause:
(I) Chemotherapy administration services.
(II) Renal dialysis services (as defined in section 1395rr(b)(14)(B) of this title ).
(III) Skilled nursing care.
(IV) Clinical diagnostic laboratory test administered during any portion of the emergency period defined in paragraph (1)(B) of section 1320b–5(g) of this title beginning on or after March 18, 2020 , for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19 and the administration of such test.
(V) Specified COVID–19 testing-related services (as described in section 1395 l (cc)(1) of this title) for which payment would be payable under a specified outpatient payment provision described in section 1395 l (cc)(2) of this title.
(VI) A COVID–19 vaccine and its administration described in section 1395x(s)(10)(A) of this title .
(VII) A drug or biological product that is a selected drug (as referred to in section 1320f–1(c) of this title ).
(VIII) Such other services that the Secretary determines appropriate (including services that the Secretary determines require a high level of predictability and transparency for beneficiaries).
Chemotherapy administration services.
Renal dialysis services (as defined in section 1395rr(b)(14)(B) of this title ).
Skilled nursing care.
Clinical diagnostic laboratory test administered during any portion of the emergency period defined in paragraph (1)(B) of section 1320b–5(g) of this title beginning on or after March 18, 2020 , for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19 and the administration of such test.
Specified COVID–19 testing-related services (as described in section 1395 l (cc)(1) of this title) for which payment would be payable under a specified outpatient payment provision described in section 1395 l (cc)(2) of this title.
A COVID–19 vaccine and its administration described in section 1395x(s)(10)(A) of this title .
A drug or biological product that is a selected drug (as referred to in section 1320f–1(c) of this title ).
Such other services that the Secretary determines appropriate (including services that the Secretary determines require a high level of predictability and transparency for beneficiaries).
In the case of services described in clause (iv), other than subclauses (IV), (V), and (VI) of such clause, for which there is no cost-sharing required under parts A and B, cost-sharing may be required for those services in accordance with clause (i).
In the case of a product or service described in subclause (IV) or (V), respectively, of clause (iv) that is administered or furnished during any portion of the emergency period described in such subclause beginning on or after March 18, 2020 , an MA plan may not impose any prior authorization or other utilization management requirements with respect to the coverage of such a product or service under such plan.