e-CFR data is current as of July 6, 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
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| Cost-sharing in enrollment-related costs. |
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Subpart B—ELIGIBILITY, ELECTION, AND ENROLLMENT
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| Eligibility to elect an MA plan. |
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| Eligibility to elect an MA plan for special needs individuals. |
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| Eligibility to elect an MA plan for senior housing facility residents. |
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| Continuation of enrollment for MA local plans. |
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| Enrollment in an MA MSA plan. |
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| Limited enrollment under MA RFB plans. |
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| Election of coverage under an MA plan. |
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| Information about the MA program. |
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| Coordination of enrollment and disenrollment through MA organizations. |
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| Effective dates of coverage and change of coverage. |
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| Disenrollment by the MA organization. |
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Subpart C—BENEFITS AND BENEFICIARY PROTECTIONS
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| Requirements relating to basic benefits. |
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| Benefits under an MA MSA plan. |
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| Special rules on supplemental benefits for MA MSA plans. |
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| Special rules for self-referral and point of service option. |
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| Coordination of benefits with employer or union group health plans and Medicaid. |
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| Special needs plans and dual eligibles: Contract with State Medicaid Agency. |
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| Medicare secondary payer (MSP) procedures. |
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| Effect of national coverage determinations (NCDs) and legislative changes in benefits. |
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| Discrimination against beneficiaries prohibited. |
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| Special rules for ambulance services, emergency and urgently needed services, and maintenance and post-stabilization care services. |
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| Access to services under an MA private fee-for-service plan. |
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| Confidentiality and accuracy of enrollee records. |
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| Access to and exchange of health data and plan information. |
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| Access to published provider directory information. |
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| Information on advance directives. |
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| Protection against liability and loss of benefits. |
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| Return to home skilled nursing facility. |
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| Reward and incentive programs. |
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| Additional telehealth benefits. |
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| Medicare Advantage (MA) and step therapy for Part B drugs. |
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Subpart D—QUALITY IMPROVEMENT
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| Quality improvement program. |
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| Use of quality improvement organization review information. |
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| Compliance deemed on the basis of accreditation. |
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| Accreditation organizations. |
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| Procedures for approval of accreditation as a basis for deeming compliance. |
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| Basis and scope of the Medicare Advantage Quality Rating System. |
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| Medicare Advantage Quality Rating System. |
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| Adding, updating, and removing measures. |
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| Calculation of Star Ratings. |
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Subpart E—RELATIONSHIPS WITH PROVIDERS
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| Participation procedures. |
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| Provider selection and credentialing. |
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| Provider antidiscrimination rules. |
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| Interference with health care professionals' advice to enrollees prohibited. |
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| Physician incentive plans: requirements and limitations. |
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| Limitations on provider indemnification. |
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| Special rules for services furnished by noncontract providers. |
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| Special rules for MA private fee-for-service plans. |
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| Exclusion of services furnished under a private contract. |
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| Preclusion list for contracted and non-contracted individuals and entities. |
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| Payment to individuals and entities excluded by the OIG or included on the preclusion list. |
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Subpart F—SUBMISSION OF BIDS, PREMIUMS, AND RELATED INFORMATION AND PLAN APPROVAL
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| Review, negotiation, and approval of bids. |
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| Calculation of benchmarks. |
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| Appeals of quality bonus payment determinations. |
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| Incorrect collections of premiums and cost-sharing. |
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| Release of MA bid pricing data. |
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Subpart G—PAYMENTS TO MEDICARE ADVANTAGE ORGANIZATIONS
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| Annual MA capitation rates. |
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| Adjustments to capitation rates, benchmarks, bids, and payments. |
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| RADV audit dispute and appeal processes. |
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| Announcement of annual capitation rate, benchmarks, and methodology changes. |
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| Special rules for beneficiaries enrolled in MA MSA plans. |
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| Special rules for payments to Federally qualified health centers. |
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| Special rules for coverage that begins or ends during an inpatient hospital stay. |
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| Special rules for hospice care. |
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| Source of payment and effect of MA plan election on payment. |
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| Payments to MA organizations for graduate medical education costs. |
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| Reporting and returning of overpayments. |
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| CMS-identified overpayments associated with payment data submitted by MA organizations. |
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Subpart H—PROVIDER-SPONSORED ORGANIZATIONS
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| Basis, scope, and definitions. |
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| Requirements for affiliated providers. |
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| Determining substantial financial risk and majority financial interest. |
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| Waiver of State licensure. |
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| Basis for waiver of State licensure. |
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| Waiver request and approval process. |
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| Conditions of the waiver. |
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| Relationship to State law. |
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| Minimum net worth amount. |
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| Financial plan requirement. |
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Subpart I—ORGANIZATION COMPLIANCE WITH STATE LAW AND PREEMPTION BY FEDERAL LAW
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| State licensure requirement. |
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| Federal preemption of State law. |
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| State premium taxes prohibited. |
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Subpart J—SPECIAL RULES FOR MA REGIONAL PLANS
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| Moratorium on new local preferred provider organization plans. |
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| Special rules for MA Regional Plans. |
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| Risk sharing with regional MA organizations for 2006 and 2007. |
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Subpart K—APPLICATION PROCEDURES AND CONTRACTS FOR MEDICARE ADVANTAGE ORGANIZATIONS
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| Application requirements. |
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| Evaluation and determination procedures. |
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| Effective date and term of contract. |
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| Modification or termination of contract by mutual consent. |
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| Termination of contract by CMS. |
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| Termination of contract by the MA organization. |
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| Minimum enrollment requirements. |
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| Validation of Part C reporting requirements. |
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| Prompt payment by MA organization. |
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| Effective date of new significant regulatory requirements. |
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| Special rules for RFB societies. |
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| Agreements with Federally qualified health centers. |
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Subpart L—EFFECT OF CHANGE OF OWNERSHIP OR LEASING OF FACILITIES DURING TERM OF CONTRACT
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| Novation agreement requirements. |
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| Effect of leasing of an MA organization's facilities. |
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Subpart M—GRIEVANCES, ORGANIZATION DETERMINATIONS AND APPEALS
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| Organization determinations. |
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| Standard timeframes and notice requirements for organization determinations. |
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| Expediting certain organization determinations. |
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| Timeframes and notice requirements for expedited organization determinations. |
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| Parties to the organization determination. |
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| Effect of an organization determination. |
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| Right to a reconsideration. |
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| Request for a standard reconsideration. |
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| Expediting certain reconsiderations. |
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| Opportunity to submit evidence. |
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| Timeframes and responsibility for reconsiderations. |
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| Reconsideration by an independent entity. |
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| Notice of reconsidered determination by the independent entity. |
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| Effect of a reconsidered determination. |
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| Request for an ALJ hearing. |
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| Medicare Appeals Council (Council) review. |
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| Reopening and revising determinations and decisions. |
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| How an MA organization must effectuate standard reconsidered determinations or decisions. |
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| How an MA organization must effectuate expedited reconsidered determinations. |
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| Notifying enrollees of hospital discharge appeal rights. |
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| Requesting immediate QIO review of the decision to discharge from the inpatient hospital. |
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| Notifying enrollees of termination of provider services. |
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| Fast-track appeals of service terminations to independent review entities (IREs). |
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Subpart N—MEDICARE CONTRACT DETERMINATIONS AND APPEALS
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| Notice of contract determination. |
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| Effect of contract determination. |
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| Right to a hearing, burden of proof, standard of proof, and standards of review. |
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| Postponement of effective date of a contract determination when a request for a hearing is filed timely. |
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| Designation of hearing officer. |
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| Disqualification of hearing officer. |
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| Time and place of hearing. |
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| Appointment of representatives. |
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| Authority of representatives. |
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| Witness lists and documents. |
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| Prehearing and summary judgment. |
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| Authority of hearing officer. |
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| Notice and effect of hearing decision. |
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| Review by the Administrator. |
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| Effect of Administrator's decision. |
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| Reopening of a contract determination or decision of a hearing officer or the Administrator. |
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Subpart O—INTERMEDIATE SANCTIONS
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| Types of intermediate sanctions and civil money penalties. |
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| Basis for imposing intermediate sanctions and civil money penalties. |
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| Procedures for imposing intermediate sanctions and civil money penalties. |
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| Collection of civil money penalties imposed by CMS. |
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| Determinations regarding the amount of civil money penalties and assessment imposed by CMS. |
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| Other applicable provisions. |
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Subparts P-S [Reserved]
Subpart T—APPEAL PROCEDURES FOR CIVIL MONEY PENALTIES
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| Appointment of representatives. |
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| Authority of representatives. |
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| Fees for services of representatives. |
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| Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal. |
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| Notice and effect of initial determinations. |
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| Designation of hearing official. |
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| Disqualification of Administrative Law Judge. |
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| Notice of prehearing conference. |
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| Conduct of prehearing conference. |
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| Record, order, and effect of prehearing conference. |
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| Time and place of hearing. |
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| Change in time and place of hearing. |
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| Oral and written summation. |
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| Waiver of right to appear and present evidence. |
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| Dismissal of request for hearing. |
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| Dismissal for abandonment. |
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| Notice and effect of dismissal and right to request review. |
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| Vacating a dismissal of request for hearing. |
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| Administrative Law Judge's decision. |
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| Removal of hearing to Departmental Appeals Board. |
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| Remand by the Administrative Law Judge. |
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| Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal. |
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| Request for Departmental Appeals Board review. |
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| Departmental Appeals Board action on request for review. |
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| Procedures before the Departmental Appeals Board on review. |
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| Evidence admissible on review. |
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| Decision or remand by the Departmental Appeals Board. |
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| Effect of Departmental Appeals Board Decision. |
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| Extension of time for seeking judicial review. |
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| Basis, timing, and authority for reopening an Administrative Law Judge or Board decision. |
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| Revision of reopened decision. |
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| Notice and effect of revised decision. |
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Subpart U—[RESERVED]
Subpart V—MEDICARE ADVANTAGE COMMUNICATION REQUIREMENTS
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| Review and distribution of marketing materials. |
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| Guidelines for CMS review. |
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| Standards for MA organization communications and marketing. |
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| Licensing of marketing representatives and confirmation of marketing resources. |
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| Broker and agent requirements. |
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| Employer group retiree marketing. |
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Subpart W—[RESERVED]
Subpart X—REQUIREMENTS FOR A MINIMUM MEDICAL LOSS RATIO
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| Calculation of the medical loss ratio. |
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| Activities that improve health care quality. |
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| Remittance to CMS if the applicable MLR requirement is not met. |
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| MLR review and non-compliance. |
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| Release of Part C MLR data. |
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Subpart Y—[RESERVED]
Subpart Z—PART C RECOVERY AUDIT CONTRACTOR APPEALS PROCESS
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| Request for reconsideration. |
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| Review by the Administrator. |
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