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Electronic Code of Federal Regulations

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e-CFR Data is current as of April 17, 2014

TITLE 42—Public Health

CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED)

SUBCHAPTER B—MEDICARE PROGRAM (CONTINUED)

PART 422—MEDICARE ADVANTAGE PROGRAM

rule

Subpart A—GENERAL PROVISIONS

§422.1
Basis and scope.
§422.2
Definitions.
§422.4
Types of MA plans.
§422.6
Cost-sharing in enrollment-related costs.
rule

Subpart B—ELIGIBILITY, ELECTION, AND ENROLLMENT

§422.50
Eligibility to elect an MA plan.
§422.52
Eligibility to elect an MA plan for special needs individuals.
§422.53
Eligibility to elect an MA plan for senior housing facility residents.
§422.54
Continuation of enrollment for MA local plans.
§422.56
Enrollment in an MA MSA plan.
§422.57
Limited enrollment under MA RFB plans.
§422.60
Election process.
§422.62
Election of coverage under an MA plan.
§422.64
Information about the MA program.
§422.66
Coordination of enrollment and disenrollment through MA organizations.
§422.68
Effective dates of coverage and change of coverage.
§422.74
Disenrollment by the MA organization.
rule

Subpart C—BENEFITS AND BENEFICIARY PROTECTIONS

§422.100
General requirements.
§422.101
Requirements relating to basic benefits.
§422.102
Supplemental benefits.
§422.103
Benefits under an MA MSA plan.
§422.104
Special rules on supplemental benefits for MA MSA plans.
§422.105
Special rules for self-referral and point of service option.
§422.106
Coordination of benefits with employer or union group health plans and Medicaid.
§422.107
Special needs plans and dual-eligibles: Contract with State Medicaid Agency.
§422.108
Medicare secondary payer (MSP) procedures.
§422.109
Effect of national coverage determinations (NCDs) and legislative changes in benefits.
§422.110
Discrimination against beneficiaries prohibited.
§422.111
Disclosure requirements.
§422.112
Access to services.
§422.113
Special rules for ambulance services, emergency and urgently needed services, and maintenance and post-stabilization care services.
§422.114
Access to services under an MA private fee-for-service plan.
§422.118
Confidentiality and accuracy of enrollee records.
§422.128
Information on advance directives.
§422.132
Protection against liability and loss of benefits.
§422.133
Return to home skilled nursing facility.
rule

Subpart D—QUALITY IMPROVEMENT

§422.152
Quality improvement program.
§422.153
Use of quality improvement organization review information.
§422.156
Compliance deemed on the basis of accreditation.
§422.157
Accreditation organizations.
§422.158
Procedures for approval of accreditation as a basis for deeming compliance.
rule

Subpart E—RELATIONSHIPS WITH PROVIDERS

§422.200
Basis and scope.
§422.202
Participation procedures.
§422.204
Provider selection and credentialing.
§422.205
Provider antidiscrimination rules.
§422.206
Interference with health care professionals' advice to enrollees prohibited.
§422.208
Physician incentive plans: requirements and limitations.
§422.210
Assurances to CMS.
§422.212
Limitations on provider indemnification.
§422.214
Special rules for services furnished by noncontract providers.
§422.216
Special rules for MA private fee-for-service plans.
§422.220
Exclusion of services furnished under a private contract.
rule

Subpart F—SUBMISSION OF BIDS, PREMIUMS, AND RELATED INFORMATION AND PLAN APPROVAL

§422.250
Basis and scope.
§422.252
Terminology.
§422.254
Submission of bids.
§422.256
Review, negotiation, and approval of bids.
§422.258
Calculation of benchmarks.
§422.260
Appeals of quality bonus payment determinations.
§422.262
Beneficiary premiums.
§422.264
Calculation of savings.
§422.266
Beneficiary rebates.
§422.270
Incorrect collections of premiums and cost-sharing.
rule

Subpart G—PAYMENTS TO MEDICARE ADVANTAGE ORGANIZATIONS

§422.300
Basis and scope.
§422.304
Monthly payments.
§422.306
Annual MA capitation rates.
§422.308
Adjustments to capitation rates, benchmarks, bids, and payments.
§422.310
Risk adjustment data.
§422.311
RADV audit dispute and appeal processes.
§422.312
Announcement of annual capitation rate, benchmarks, and methodology changes.
§422.314
Special rules for beneficiaries enrolled in MA MSA plans.
§422.316
Special rules for payments to Federally qualified health centers.
§422.318
Special rules for coverage that begins or ends during an inpatient hospital stay.
§422.320
Special rules for hospice care.
§422.322
Source of payment and effect of MA plan election on payment.
§422.324
Payments to MA organizations for graduate medical education costs.
rule

Subpart H—PROVIDER-SPONSORED ORGANIZATIONS

§422.350
Basis, scope, and definitions.
§422.352
Basic requirements.
§422.354
Requirements for affiliated providers.
§422.356
Determining substantial financial risk and majority financial interest.
§422.370
Waiver of State licensure.
§422.372
Basis for waiver of State licensure.
§422.374
Waiver request and approval process.
§422.376
Conditions of the waiver.
§422.378
Relationship to State law.
§422.380
Solvency standards.
§422.382
Minimum net worth amount.
§422.384
Financial plan requirement.
§422.386
Liquidity.
§422.388
Deposits.
§422.390
Guarantees.
rule

Subpart I—ORGANIZATION COMPLIANCE WITH STATE LAW AND PREEMPTION BY FEDERAL LAW

§422.400
State licensure requirement.
§422.402
Federal preemption of State law.
§422.404
State premium taxes prohibited.
rule

Subpart J—SPECIAL RULES FOR MA REGIONAL PLANS

§422.451
Moratorium on new local preferred provider organization plans.
§422.455
Special rules for MA Regional Plans.
§422.458
Risk sharing with regional MA organizations for 2006 and 2007.
rule

Subpart K—APPLICATION PROCEDURES AND CONTRACTS FOR MEDICARE ADVANTAGE ORGANIZATIONS

§422.500
Scope and definitions.
§422.501
Application requirements.
§422.502
Evaluation and determination procedures.
§422.503
General provisions.
§422.504
Contract provisions.
§422.505
Effective date and term of contract.
§422.506
Nonrenewal of contract.
§422.508
Modification or termination of contract by mutual consent.
§422.510
Termination of contract by CMS.
§422.512
Termination of contract by the MA organization.
§422.514
Minimum enrollment requirements.
§422.516
Validation of Part C reporting requirements.
§422.520
Prompt payment by MA organization.
§422.521
Effective date of new significant regulatory requirements.
§422.524
Special rules for RFB societies.
§422.527
Agreements with Federally qualified health centers.
rule

Subpart L—EFFECT OF CHANGE OF OWNERSHIP OR LEASING OF FACILITIES DURING TERM OF CONTRACT

§422.550
General provisions.
§422.552
Novation agreement requirements.
§422.553
Effect of leasing of an MA organization's facilities.
rule

Subpart M—GRIEVANCES, ORGANIZATION DETERMINATIONS AND APPEALS

§422.560
Basis and scope.
§422.561
Definitions.
§422.562
General provisions.
§422.564
Grievance procedures.
§422.566
Organization determinations.
§422.568
Standard timeframes and notice requirements for organization determinations.
§422.570
Expediting certain organization determinations.
§422.572
Timeframes and notice requirements for expedited organization determinations.
§422.574
Parties to the organization determination.
§422.576
Effect of an organization determination.
§422.578
Right to a reconsideration.
§422.580
Reconsideration defined.
§422.582
Request for a standard reconsideration.
§422.584
Expediting certain reconsiderations.
§422.586
Opportunity to submit evidence.
§422.590
Timeframes and responsibility for reconsiderations.
§422.592
Reconsideration by an independent entity.
§422.594
Notice of reconsidered determination by the independent entity.
§422.596
Effect of a reconsidered determination.
§422.600
Right to a hearing.
§422.602
Request for an ALJ hearing.
§422.608
Medicare Appeals Council (MAC) review.
§422.612
Judicial review.
§422.616
Reopening and revising determinations and decisions.
§422.618
How an MA organization must effectuate standard reconsidered determinations or decisions.
§422.619
How an MA organization must effectuate expedited reconsidered determinations.
§422.620
Notifying enrollees of hospital discharge appeal rights.
§422.622
Requesting immediate QIO review of the decision to discharge from the inpatient hospital.
§422.624
Notifying enrollees of termination of provider services.
§422.626
Fast-track appeals of service terminations to independent review entities (IREs).
rule

Subpart N—MEDICARE CONTRACT DETERMINATIONS AND APPEALS

§422.641
Contract determinations.
§422.644
Notice of contract determination.
§422.646
Effect of contract determination.
§422.660
Right to a hearing, burden of proof, standard of proof, and standards of review.
§422.662
Request for hearing.
§422.664
Postponement of effective date of a contract determination when a request for a hearing is filed timely.
§422.666
Designation of hearing officer.
§422.668
Disqualification of hearing officer.
§422.670
Time and place of hearing.
§422.672
Appointment of representatives.
§422.674
Authority of representatives.
§422.676
Conduct of hearing.
§422.678
Evidence.
§422.680
Witnesses.
§422.682
Witness lists and documents.
§422.684
Prehearing and summary judgment.
§422.686
Record of hearing.
§422.688
Authority of hearing officer.
§422.690
Notice and effect of hearing decision.
§422.692
Review by the Administrator.
§422.694
Effect of Administrator's decision.
§422.696
Reopening of a contract determination or decision of a hearing officer or the Administrator.
rule

Subpart O—INTERMEDIATE SANCTIONS

§422.750
Types of intermediate sanctions and civil money penalties.
§422.752
Basis for imposing intermediate sanctions and civil money penalties.
§422.756
Procedures for imposing intermediate sanctions and civil money penalties.
§422.758
Collection of civil money penalties imposed by CMS.
§422.760
Determinations regarding the amount of civil money penalties and assessment imposed by CMS.
§422.762
Settlement of penalties.
§422.764
Other applicable provisions.
rule

Subparts P-S [Reserved]

rule

Subpart T—APPEAL PROCEDURES FOR CIVIL MONEY PENALTIES

§422.1000
Basis and scope.
§422.1002
Definitions.
§422.1004
Scope and applicability.
§422.1006
Appeal rights.
§422.1008
Appointment of representatives.
§422.1010
Authority of representatives.
§422.1012
Fees for services of representatives.
§422.1014
Charge for transcripts.
§422.1016
Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal.
§422.1018
Notice and effect of initial determinations.
§422.1020
Request for hearing.
§422.1022
Parties to the hearing.
§422.1024
Designation of hearing official.
§422.1026
Disqualification of Administrative Law Judge.
§422.1028
Prehearing conference.
§422.1030
Notice of prehearing conference.
§422.1032
Conduct of prehearing conference.
§422.1034
Record, order, and effect of prehearing conference.
§422.1036
Time and place of hearing.
§422.1038
Change in time and place of hearing.
§422.1040
Joint hearings.
§422.1042
Hearing on new issues.
§422.1044
Subpoenas.
§422.1046
Conduct of hearing.
§422.1048
Evidence.
§422.1050
Witnesses.
§422.1052
Oral and written summation.
§422.1054
Record of hearing.
§422.1056
Waiver of right to appear and present evidence.
§422.1058
Dismissal of request for hearing.
§422.1060
Dismissal for abandonment.
§422.1062
Dismissal for cause.
§422.1064
Notice and effect of dismissal and right to request review.
§422.1066
Vacating a dismissal of request for hearing.
§422.1068
Administrative Law Judge's decision.
§422.1070
Removal of hearing to Departmental Appeals Board.
§422.1072
Remand by the Administrative Law Judge.
§422.1074
Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal.
§422.1076
Request for Departmental Appeals Board review.
§422.1078
Departmental Appeals Board action on request for review.
§422.1080
Procedures before the Departmental Appeals Board on review.
§422.1082
Evidence admissible on review.
§422.1084
Decision or remand by the Departmental Appeals Board.
§422.1086
Effect of Departmental Appeals Board Decision.
§422.1088
Extension of time for seeking judicial review.
§422.1090
Basis, timing, and authority for reopening an Administrative Law Judge or Board decision.
§422.1092
Revision of reopened decision.
§422.1094
Notice and effect of revised decision.
rule

Subpart U—[RESERVED]

rule

Subpart V—MEDICARE ADVANTAGE MARKETING REQUIREMENTS

§422.2260
Definitions concerning marketing materials.
§422.2262
Review and distribution of marketing materials.
§422.2264
Guidelines for CMS review.
§422.2266
Deemed approval.
§422.2268
Standards for MA organization marketing.
§422.2272
Licensing of marketing representatives and confirmation of marketing resources.
§422.2274
Broker and agent requirements.
§422.2276
Employer group retiree marketing.
rule

Subpart W—[RESERVED]

rule

Subpart X—REQUIREMENTS FOR A MINIMUM MEDICAL LOSS RATIO

§422.2400
Basis and scope.
§422.2401
Definitions.
§422.2410
General requirements.
§422.2420
Calculation of the medical loss ratio.
§422.2430
Activities that improve health care quality.
§422.2440
Credibility adjustment.
§422.2450
[Reserved]
§422.2460
Reporting requirements.
§422.2470
Remittance to CMS if the applicable MLR requirement is not met.
§422.2480
MLR review and non-compliance.


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