42 C.F.R. PART 422--MEDICARE ADVANTAGE PROGRAM
TITLE 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B--MEDICARE PROGRAM
PART 422--MEDICARE ADVANTAGE PROGRAM
Subpart A--GENERAL PROVISIONS
|
|
| Cost-sharing in enrollment-related costs.
|
|
Subpart B--ELIGIBILITY, ELECTION, AND ENROLLMENT
|
|
| Eligibility to elect an MA plan.
|
|
|
|
| Eligibility to elect an MA plan for special needs individuals.
|
|
|
|
| Continuation of enrollment for MA local plans.
|
|
|
|
| Enrollment in an MA MSA plan.
|
|
|
|
| Limited enrollment under MA RFB plans.
|
|
|
|
| Election of coverage under an MA plan.
|
|
|
|
| Information about the MA program.
|
|
|
|
| Coordination of enrollment and disenrollment through MA organizations.
|
|
|
|
| Effective dates of coverage and change of coverage.
|
|
|
|
| Disenrollment by the MA organization.
|
|
|
|
| Approval of marketing materials and election forms.
|
|
Subpart C--BENEFITS AND BENEFICIARY PROTECTIONS
|
|
| Requirements relating to basic benefits.
|
|
|
|
| Benefits under an MA MSA plan.
|
|
|
|
| Special rules on supplemental benefits for MA MSA plans.
|
|
|
|
| Special rules for self-referral and point of service option.
|
|
|
|
| Coordination of benefits with employer or union group health plans and Medicaid.
|
|
|
|
| Medicare secondary payer (MSP) procedures.
|
|
|
|
| Effect of national coverage determinations (NCDs) and legislative changes in benefits.
|
|
|
|
| Discrimination against beneficiaries prohibited.
|
|
|
|
| Special rules for ambulance services, emergency and urgently needed services, and maintenance and post-stabilization care services.
|
|
|
|
| Access to services under an MA private fee-for-service plan.
|
|
|
|
| Confidentiality and accuracy of enrollee records.
|
|
|
|
| Information on advance directives.
|
|
|
|
| Protection against liability and loss of benefits.
|
|
|
|
| Return to home skilled nursing facility.
|
|
Subpart D--QUALITY IMPROVEMENT
|
|
| Quality improvement program.
|
|
|
|
| Compliance deemed on the basis of accreditation.
|
|
|
|
| Accreditation organizations.
|
|
|
|
| Procedures for approval of accreditation as a basis for deeming compliance.
|
|
Subpart E--RELATIONSHIPS WITH PROVIDERS
|
|
| Participation procedures.
|
|
|
|
| Provider selection and credentialing.
|
|
|
|
| Provider antidiscrimination rules.
|
|
|
|
| Interference with health care professionals' advice to enrollees prohibited.
|
|
|
|
| Physician incentive plans: requirements and limitations.
|
|
|
|
| Limitations on provider indemnification.
|
|
|
|
| Special rules for services furnished by noncontract providers.
|
|
|
|
| Special rules for MA private fee-for-service plans.
|
|
|
|
| Exclusion of services furnished under a private contract.
|
|
Subpart F-SUBMISSION OF BIDS, PREMIUMS, AND RELATED INFORMATION AND PLAN APPROVAL
|
|
| Review, negotiation, and approval of bids.
|
|
|
|
| Calculation of benchmarks.
|
|
|
|
| Incorrect collections of premiums and cost-sharing.
|
|
Subpart G--PAYMENTS TO MEDICARE ADVANTAGE ORGANIZATIONS
|
|
| Annual MA capitation rates.
|
|
|
|
| Adjustments to capitation rates, benchmarks, bids, and payments.
|
|
|
|
| Announcement of annual capitation rate, benchmarks, and methodology changes.
|
|
|
|
| Special rules for beneficiaries enrolled in MA MSA plans.
|
|
|
|
| Special rules for payments to Federally qualified health centers.
|
|
|
|
| Special rules for coverage that begins or ends during an inpatient hospital stay.
|
|
|
|
| Special rules for hospice care.
|
|
|
|
| Source of payment and effect of MA plan election on payment.
|
|
|
|
| Payments to MA organizations for graduate medical education costs.
|
|
Subpart H--PROVIDER-SPONSORED ORGANIZATIONS
|
|
| Basis, scope, and definitions.
|
|
|
|
| Requirements for affiliated providers.
|
|
|
|
| Determining substantial financial risk and majority financial interest.
|
|
|
|
| Waiver of State licensure.
|
|
|
|
| Basis for waiver of State licensure.
|
|
|
|
| Waiver request and approval process.
|
|
|
|
| Conditions of the waiver.
|
|
|
|
| Relationship to State law.
|
|
|
|
| Minimum net worth amount.
|
|
|
|
| Financial plan requirement.
|
|
Subpart I--ORGANIZATION COMPLIANCE WITH STATE LAW AND PREEMPTION BY FEDERAL LAW
|
|
| State licensure requirement.
|
|
|
|
| Federal preemption of State law.
|
|
|
|
| State premium taxes prohibited.
|
|
Subpart J--SPECIAL RULES FOR MA REGIONAL PLANS
|
|
| Moratorium on new local preferred provider organization plans.
|
|
|
|
| Special rules for MA Regional Plans.
|
|
|
|
| Risk sharing with regional MA organizations for 2006 and 2007.
|
|
Subpart K--CONTRACTS WITH MEDICARE ADVANTAGE ORGANIZATIONS
|
|
| Application requirements.
|
|
|
|
| Evaluation and determination procedures.
|
|
|
|
| Effective date and term of contract.
|
|
|
|
| Modification or termination of contract by mutual consent.
|
|
|
|
| Termination of contract by CMS.
|
|
|
|
| Termination of contract by the MA organization.
|
|
|
|
| Minimum enrollment requirements.
|
|
|
|
| Prompt payment by MA organization.
|
|
|
|
| Effective date of new significant regulatory requirements.
|
|
|
|
| Special rules for RFB societies.
|
|
|
|
| Agreements with Federally qualified health centers.
|
|
Subpart L--EFFECT OF CHANGE OF OWNERSHIP OR LEASING OF FACILITIES DURING TERM OF CONTRACT
|
|
| Novation agreement requirements.
|
|
|
|
| Effect of leasing of an MA organization's facilities.
|
|
Subpart M--GRIEVANCES, ORGANIZATION DETERMINATIONS AND APPEALS
|
|
| Organization determinations.
|
|
|
|
| Standard timeframes and notice requirements for organization determinations.
|
|
|
|
| Expediting certain organization determinations.
|
|
|
|
| Timeframes and notice requirements for expedited organization determinations.
|
|
|
|
| Parties to the organization determination.
|
|
|
|
| Effect of an organization determination.
|
|
|
|
| Right to a reconsideration.
|
|
|
|
| Request for a standard reconsideration.
|
|
|
|
| Expediting certain reconsiderations.
|
|
|
|
| Opportunity to submit evidence.
|
|
|
|
| Timeframes and responsibility for reconsiderations.
|
|
|
|
| Reconsideration by an independent entity.
|
|
|
|
| Notice of reconsidered determination by the independent entity.
|
|
|
|
| Effect of a reconsidered determination.
|
|
|
|
| Request for an ALJ hearing.
|
|
|
|
| Medicare Appeals Council (MAC) review.
|
|
|
|
| Reopening and revising determinations and decisions.
|
|
|
|
| How an MA organization must effectuate standard reconsidered determinations or decisions.
|
|
|
|
| How an MA organization must effectuate expedited reconsidered determinations.
|
|
|
|
| How enrollees of MA organizations must be notified of noncovered inpatient hospital care.
|
|
|
|
| Requesting immediate QIO review of noncoverage of inpatient hospital care.
|
|
|
|
| Notifying enrollees of termination of provider services.
|
|
|
|
| Fast-track appeals of service terminations to independent review entities (IREs).
|
|
Subpart N--MEDICARE CONTRACT DETERMINATIONS AND APPEALS
|
|
| Notice of contract determination.
|
|
|
|
| Effect of contract determination.
|
|
|
|
| Reconsideration: Applicability.
|
|
|
|
| Request for reconsideration.
|
|
|
|
| Opportunity to submit evidence.
|
|
|
|
| Reconsidered determination.
|
|
|
|
| Notice of reconsidered determination.
|
|
|
|
| Effect of reconsidered determination.
|
|
|
|
| Postponement of effective date of a contract determination when a request for a hearing with respect to a contract determination is filed timely.
|
|
|
|
| Designation of hearing officer.
|
|
|
|
| Disqualification of hearing officer.
|
|
|
|
| Time and place of hearing.
|
|
|
|
| Appointment of representatives.
|
|
|
|
| Authority of representatives.
|
|
|
|
| Authority of hearing officer.
|
|
|
|
| Notice and effect of hearing decision.
|
|
|
|
| Review by the Administrator.
|
|
|
|
| Effect of Administrator's decision.
|
|
|
|
| Reopening of contract or reconsidered determination or decision of a hearing officer or the Administrator.
|
|
|
|
| Effect of revised determination.
|
|
Subpart O--INTERMEDIATE SANCTIONS
|
|
| Basis for imposing sanctions.
|
|
|
|
| Procedures for imposing sanctions.
|
|
|
|
| Maximum amount of civil money penalties imposed by CMS.
|
|
|
|
| Other applicable provisions.
|
|