e-CFR data is current as of January 23, 2020
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
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. |
|
|
| Eligibility to elect an MA plan for senior housing facility residents. |
|
|
| 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. |
|
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. |
|
|
| Special needs plans and dual eligibles: Contract with State Medicaid Agency. |
|
|
| 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. |
|
|
| Reward and incentive programs. |
|
|
| Additional telehealth benefits. |
|
|
| Medicare Advantage (MA) and step therapy for Part B drugs. |
|
Subpart D—QUALITY IMPROVEMENT
|
| Quality improvement program. |
|
|
| Use of quality improvement organization review information. |
|
|
| Compliance deemed on the basis of accreditation. |
|
|
| Accreditation organizations. |
|
|
| Procedures for approval of accreditation as a basis for deeming compliance. |
|
|
| Basis and scope of the Medicare Advantage Quality Rating System. |
|
|
| Medicare Advantage Quality Rating System. |
|
|
| Adding, updating, and removing measures. |
|
|
| Calculation of Star Ratings. |
|
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. |
|
|
| Preclusion list for contracted and non-contracted individuals and entities. |
|
|
| Payment to individuals and entities excluded by the OIG or included on the preclusion list. |
|
Subpart F—SUBMISSION OF BIDS, PREMIUMS, AND RELATED INFORMATION AND PLAN APPROVAL
|
| Review, negotiation, and approval of bids. |
|
|
| Calculation of benchmarks. |
|
|
| Appeals of quality bonus payment determinations. |
|
|
| Incorrect collections of premiums and cost-sharing. |
|
|
| Release of MA bid pricing data. |
|
Subpart G—PAYMENTS TO MEDICARE ADVANTAGE ORGANIZATIONS
|
| Annual MA capitation rates. |
|
|
| Adjustments to capitation rates, benchmarks, bids, and payments. |
|
|
| RADV audit dispute and appeal processes. |
|
|
| 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. |
|
|
| Reporting and returning of overpayments. |
|
|
| CMS-identified overpayments associated with payment data submitted by MA organizations. |
|
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—APPLICATION PROCEDURES AND CONTRACTS FOR 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. |
|
|
| Validation of Part C reporting 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 (Council) 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. |
|
|
| Notifying enrollees of hospital discharge appeal rights. |
|
|
| Requesting immediate QIO review of the decision to discharge from the inpatient hospital. |
|
|
| 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. |
|
|
| Right to a hearing, burden of proof, standard of proof, and standards of review. |
|
|
| Postponement of effective date of a contract determination when a request for a hearing is filed timely. |
|
|
| Designation of hearing officer. |
|
|
| Disqualification of hearing officer. |
|
|
| Time and place of hearing. |
|
|
| Appointment of representatives. |
|
|
| Authority of representatives. |
|
|
| Witness lists and documents. |
|
|
| Prehearing and summary judgment. |
|
|
| Authority of hearing officer. |
|
|
| Notice and effect of hearing decision. |
|
|
| Review by the Administrator. |
|
|
| Effect of Administrator's decision. |
|
|
| Reopening of a contract determination or decision of a hearing officer or the Administrator. |
|
Subpart O—INTERMEDIATE SANCTIONS
|
| Types of intermediate sanctions and civil money penalties. |
|
|
| Basis for imposing intermediate sanctions and civil money penalties. |
|
|
| Procedures for imposing intermediate sanctions and civil money penalties. |
|
|
| Collection of civil money penalties imposed by CMS. |
|
|
| Determinations regarding the amount of civil money penalties and assessment imposed by CMS. |
|
|
| Other applicable provisions. |
|
Subparts P-S [Reserved]
Subpart T—APPEAL PROCEDURES FOR CIVIL MONEY PENALTIES
|
| Appointment of representatives. |
|
|
| Authority of representatives. |
|
|
| Fees for services of representatives. |
|
|
| Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal. |
|
|
| Notice and effect of initial determinations. |
|
|
| Designation of hearing official. |
|
|
| Disqualification of Administrative Law Judge. |
|
|
| Notice of prehearing conference. |
|
|
| Conduct of prehearing conference. |
|
|
| Record, order, and effect of prehearing conference. |
|
|
| Time and place of hearing. |
|
|
| Change in time and place of hearing. |
|
|
| Oral and written summation. |
|
|
| Waiver of right to appear and present evidence. |
|
|
| Dismissal of request for hearing. |
|
|
| Dismissal for abandonment. |
|
|
| Notice and effect of dismissal and right to request review. |
|
|
| Vacating a dismissal of request for hearing. |
|
|
| Administrative Law Judge's decision. |
|
|
| Removal of hearing to Departmental Appeals Board. |
|
|
| Remand by the Administrative Law Judge. |
|
|
| Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal. |
|
|
| Request for Departmental Appeals Board review. |
|
|
| Departmental Appeals Board action on request for review. |
|
|
| Procedures before the Departmental Appeals Board on review. |
|
|
| Evidence admissible on review. |
|
|
| Decision or remand by the Departmental Appeals Board. |
|
|
| Effect of Departmental Appeals Board Decision. |
|
|
| Extension of time for seeking judicial review. |
|
|
| Basis, timing, and authority for reopening an Administrative Law Judge or Board decision. |
|
|
| Revision of reopened decision. |
|
|
| Notice and effect of revised decision. |
|
Subpart U—[RESERVED]
Subpart V—MEDICARE ADVANTAGE COMMUNICATION REQUIREMENTS
|
| Review and distribution of marketing materials. |
|
|
| Guidelines for CMS review. |
|
|
| Standards for MA organization communications and marketing. |
|
|
| Licensing of marketing representatives and confirmation of marketing resources. |
|
|
| Broker and agent requirements. |
|
|
| Employer group retiree marketing. |
|
Subpart W—[RESERVED]
Subpart X—REQUIREMENTS FOR A MINIMUM MEDICAL LOSS RATIO
|
| Calculation of the medical loss ratio. |
|
|
| Activities that improve health care quality. |
|
|
| Remittance to CMS if the applicable MLR requirement is not met. |
|
|
| MLR review and non-compliance. |
|
|
| Release of Part C MLR data. |
|
Subpart Y—[RESERVED]
Subpart Z—PART C RECOVERY AUDIT CONTRACTOR APPEALS PROCESS
|
| Request for reconsideration. |
|
|
| Review by the Administrator. |
|
| 
