An MA organization must make timely and reasonable payment to or on behalf of the plan enrollee for the following services obtained from a provider or supplier that does not contract with the MA organization to provide services covered by the MA plan:
- Ambulance services dispatched through 911 or its local equivalent
- Emergency and urgently needed services
- Maintenance and post-stabilization care services
- Renal dialysis services provided while the enrollee was temporarily outside the plan’s service area
- Services for which coverage has been denied by the MA organization and found (upon appeal) to be services the enrollee was entitled to have furnished, or paid for, by the MA organization
Enrollees of MA organizations may directly access (through self-referral) screening mammography and influenza vaccine.
MA organizations may not impose cost-sharing for the influenza vaccine and pneumococcal vaccine on their MA plan enrollees.