Form Cms-576a - Health Insurance Benefits Agreement With Organ Procurement Organization

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

OMB No. 0938-0512

CENTERS FOR MEDICARE & MEDICAID SERVICES

HEALTH INSURANCE BENEFITS AGREEMENT

AGREEMENT WITH ORGAN PROCUREMENT ORGANIZATION PURSUANT TO §1138(b) OF THE SOCIAL SECURITY ACT (the Act)

For the purpose of establishing eligibility under titles XVIII and XIX of the Act______________________________________________________________

hereinafter referred to as the Organ Procurement Organization, hereby agrees;

(Insert Name of Facility)

(A) To maintain compliance with the requirements of titles XVIII and XIX of the Act, §1138 of the Act, applicable regulations including the

conditions set forth in Part 486, subpart G, title 42 of the Code of Federal Regulations, those conditions of the Organ Procurement and

Transplantation Network established under §372 of the Public Health Service Act that have been approved by the Secretary, and to report

promptly to the Centers for Medicare & Medicaid Services (CMS) any failure to do so;

(B) To file a cost report in accordance with 42 CFR 413.24(f) within 5 months after the end of each fiscal year;

(C) To permit CMS to designate an intermediary to determine the interim reimbursement rate payable to the transplant hospitals for services

provided by the OPO and to make a determination of reasonable cost based upon the cost report filed by the OPOs;

(D) To provide such budget or cost projection information as may be required to establish an initial interim reimbursement rate;

(E) To pay to CMS amounts that have been paid by CMS to transplant hospitals and that are determined to be in excess of the reasonable cost of

the services provided by the OPO;

(F) Not to charge any individual for items or services for which that individual is entitled to have payment made under §1881 of the Act;

This agreement, upon submission by the Organ Procurement Organization and upon acceptance for filing by the Secretary of Health and Human

Services, shall be binding on the Organ Procurement Organization and the Secretary. The agreement may be terminated by either party in

accordance with regulatory requirements. In the event of de-certification, costs for the procurement of organs will not be available to the Organ

Procurement Organization furnished on or after the effective date of the de-certification.

This agreement shall become effective on the date specified below by the Secretary or his Delegate, and shall remain in effect as specified by

42 CFR 486.309 unless the OPO is de-certified.

FOR THE ORGAN PROCUREMENT ORGANIZATION

ACCEPTED FOR SECRETARY OF HEALTH AND HUMAN SERVICES BY:

NAME

TITLE

DATE

EFFECTIVE DATE OF AGREEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control

number for this information collection is 0938-0512. The time required to complete this information collection is estimated to average 2 hours per response, including the time to review

instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time

estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Form CMS-576A (06/06)