e-CFR data is current as of March 1, 2021
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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MA organizations' use of reinsurance. |
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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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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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Requirements Applicable to Certain Integrated Dual Eligible Special Needs Plans
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General requirements for applicable integrated plans. |
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Integrated organization determinations. |
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Continuation of benefits while the applicable integrated plan reconsideration is pending. |
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Integrated reconsideration. |
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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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