Form CMS-576A Health Insurance Benefits Agreement

Department of Health & Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0512
_______________________________________________________________________________________________________________________________________________________________________________

HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
(CMS-576A)
For the purpose of establishing eligibility under titles XVIII and XIX of the Social Security Act (“the Act”),
hereinafter referred to as the Organ Procurement Organization (OPO), hereby agrees;

(A) To maintain compliance with the requirements of titles XVIII and XIX of the Act, §1138 of the Act, applicable Centers for Medicare
and Medicaid Services (CMS) regulations, including, but not limited to the conditions and requirements set forth in Part 486, subpart
G, title 42 of the Code of Federal Regulations (CFR), those conditions of the Organ Procurement and Transplantation Network
established under §§371 and 372 of the Public Health Service Act, and to report promptly to CMS any failure to do so;
(B) To file a cost report in accordance with 42 CFR § 413.24(f) within 5 months following the close of the period covered by the report;

(C) To permit CMS to designate a contractor to determine the interim reimbursement rates payable by the transplant hospitals for
services provided by the Independent Organ Procurement Organization (IOPO), and to determine Medicare’s reasonable cost based
upon the cost reports filed by the IOPOs;

(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 IOPO;
(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 OPO and upon acceptance for filing by CMS on behalf of the Secretary of Health and

Human Services (the Secretary), shall be binding on the OPO and the Secretary.
Form CMS-576A / OMB Approval Expires XX/XX/20XX

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Department of Health & Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0512
_______________________________________________________________________________________________________________________________________________________________________________

HEALTH INSURANCE BENEFITS AGREEMENT

I

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
(CMS-576A)

This 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 OPO 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 its’ Delegate, and shall remain in effect as
specified by 42 CFR §486.309 unless the OPO is de-certified.
Agreement Entered into on Behalf of the OPO by:

Accepted for Secretary of Health and Human Services By:

Printed Name of OPO Representative:

Printed Name of CMS Representative:

Title:

Title:

Signature of OPO Representative:

Signature of CMS Representative:

Date Signed:

Date Signed:
Effective Date of Agreement: (to be completed by CMS only):

Form CMS-576A / OMB Approval Expires XX/XX/20XX

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Department of Health & Human Services
Form Approved
Centers for Medicare & Medicaid Services
OMB No. 0938-0512
_______________________________________________________________________________________________________________________________________________________________________________

HEALTH INSURANCE BENEFITS AGREEMENT

Agreement with Organ Procurement Organization Pursuant To §1138(B) of the Social Security Act
(CMS-576A)

PRA Disclosure Statement
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 (Expires XX/XX/20XX). This is a required information collection. The time required to
complete this information collection is estimated to average of 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 comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

****CMS Disclosure Statement****
Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents,
please contact [email protected].

Form CMS-576A / OMB Approval Expires XX/XX/20XX

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