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42 U.S.C. 1302, 1315a, and 1395hh.
85 FR 61362, Sept. 29, 2020, unless otherwise noted.
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(a) Beneficiary inclusion criteria. An individual is an RO beneficiary if:
(1) The individual receives included RT services from an RO participant that billed the SOE modifier for the PC or TC of an RO episode during the Model performance period for an included cancer type; and
(2) At the time that the initial treatment planning service of an RO episode is furnished by an RO participant, the individual:
(i) Is eligible for Medicare Part A and enrolled in Medicare Part B;
(ii) Has traditional FFS Medicare as his or her primary payer (for example, is not enrolled in a PACE plan, Medicare Advantage or another managed care plan, or United Mine Workers insurance); and
(iii) Is not in a Medicare hospice benefit period.
(b) Any individual enrolled in a clinical trial for RT services for which Medicare pays routine costs is an RO beneficiary if the individual satisfies all of the beneficiary inclusion criteria in paragraph (a) of this section.