Form CMS-576A Health Insurance Benefits Agreement

Form Approved
OMB No. 0938-0512

DEPARTMENT OF HEALTH AND HUMAN SERVICES
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

NAME

TITLE

TITLE

DATE

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 09380512 (Expiration date: XX/XX/XXXX). The time required to complete this information collection is estimated to average 30 minutes 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