42 C.F.R. § 422.510 Termination of contract by CMS.
Title 42 - Public Health
(a) Termination by CMS. CMS may terminate a contract for any of the following reasons: (1) The MA organization has failed substantially to carry out the terms of its contract with CMS. (2) The MA organization is carrying out its contract with CMS in a manner that is inconsistent with the effective and efficient implementation of this part. (3) CMS determines that the MA organization no longer meets the requirements of this part for being a contracting organization. (4) There is credible evidence that the MA organization committed or participated in false, fraudulent, or abusive activities affecting the Medicare program, including submission of false or fraudulent data. (5) The MA organization experiences financial difficulties so severe that its ability to make necessary health services available is impaired to the point of posing an imminent and serious risk to the health of its enrollees, or otherwise fails to make services available to the extent that such a risk to health exists. (6) The MA organization substantially fails to comply with the requirements in subpart M of this part relating to grievances and appeals. (7) The MA organization fails to provide CMS with valid data as required under §422.310. (8) The MA organization fails to implement an acceptable quality assessment and performance improvement program as required under subpart D of this part. (9) The MA organization substantially fails to comply with the prompt payment requirements in §422.520. (10) The MA organization substantially fails to comply with the service access requirements in §422.112 or §422.114. (11) The MA organization fails to comply with the requirements of §422.208 regarding physician incentive plans. (12) The MA organization substantially fails to comply with the marketing requirements in §422.80. (b) Notice. If CMS decides to terminate a contract for reasons other than the grounds specified in §422.510(a)(5), it gives notice of the termination as follows: (1) Termination of contract by CMS. (i) CMS notifies the MA organization in writing 90 days before the intended date of the termination. (ii) The MA organization notifies its Medicare enrollees of the termination by mail at least 30 days before the effective date of the termination. (iii) The MA organization notifies the general public of the termination at least 30 days before the effective date of the termination by publishing a notice in one or more newspapers of general circulation in each community or county located in the MA organization's service area. (2) Immediate termination of contract by CMS. (i) For terminations based on violations prescribed in §422.510(a)(5), CMS notifies the MA organization in writing that its contract has been terminated effective the date of the termination decision by CMS. If termination is effective in the middle of a month, CMS has the right to recover the prorated share of the capitation payments made to the MA organization covering the period of the month following the contract termination. (ii) CMS notifies the MA organization's Medicare enrollees in writing of CMS's decision to terminate the MA organization's contract. This notice occurs no later than 30 days after CMS notifies the plan of its decision to terminate the MA contract. CMS simultaneously informs the Medicare enrollees of alternative options for obtaining Medicare services, including alternative MA organizations in a similar geographic area and original Medicare. (iii) CMS notifies the general public of the termination no later than 30 days after notifying the plan of CMS's decision to terminate the MA contract. This notice is published in one or more newspapers of general circulation in each community or county located in the MA organization's service area. (c) Corrective action plan—(1) General. Before terminating a contract for reasons other than the grounds specified in paragraph (a)(5) of this section, CMS provides the MA organization with reasonable opportunity to develop and receive CMS approval of a corrective action plan to correct the deficiencies that are the basis of the proposed termination. (2) Exception. If a contract is terminated under §422.510(a)(5), the MA organization will not have the opportunity to submit a corrective action plan. (d) Appeal rights. If CMS decides to terminate a contract, it sends written notice to the MA organization informing it of its termination appeal rights in accordance with subpart N of this part. [63 FR 35099, June 26, 1998, as amended at 65 FR 40328, June 29, 2000; 70 FR 52027, Sept. 1, 2005]
Title 42: Public Health
PART 422—MEDICARE ADVANTAGE PROGRAM
Subpart K—Contracts With Medicare Advantage Organizations
§ 422.510 Termination of contract by CMS.
