An enrollee who relied on a wrong listing pays only the in-network share
What the document says“the MA organization offering such plan shall ensure that the enrollee is only responsible for the lesser of-- ``(i) the amount of cost sharing that would apply if such provider had been participating in the network of such plan; or ``(ii) the amount of cost sharing that would otherwise apply (without regard to this subparagraph).”
Section 6220 adds a new paragraph (7) to section 1852(d) of the Social Security Act. For plan year 2028 and later, where an enrollee in a specified MA plan is served by a provider outside the network who was listed in the directory on the date the appointment was made, and the item or service would have been covered in network, the organization must ensure the enrollee pays only the lesser of the in-network cost sharing or what would otherwise apply.
What the document actually says“the MA organization offering such plan shall ensure that the enrollee is only responsible for the lesser of-- ``(i) the amount of cost sharing that would apply if such provider had been participating in the network of such plan; or ``(ii) the amount of cost sharing that would otherwise apply (without regard to this subparagraph).”
The plan must make sure the patient pays the smaller of two amounts. One is what a doctor in the group would cost. The other is what would be charged anyway.
The date that counts is the day the visit was booked. If the list was wrong that day, the patient does not pay for the mistake.
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