42 C.F.R. § 422.752 Basis for imposing sanctions.
Title 42 - Public Health
(a) All intermediate sanctions. For the violations listed in this paragraph (a), we may impose one, or more, of the sanctions specified in §422.750(a)(2), (a)(3), or (a)(4) on any MA organization that has a contract in effect. The MA organization may also be subject to other applicable remedies available under law. (1) Fails substantially to provide, to an MA enrollee, medically necessary services that the organization is required to provide (under law or under the contract) to an MA enrollee, and that failure adversely affects (or is substantially likely to adversely affect) the enrollee. (2) Imposes on MA enrollees premiums in excess of the monthly basic and supplemental beneficiary premiums permitted under section 1854 of the Act and subpart F of this part. (3) Expels or refuses to reenroll a beneficiary in violation of the provisions of this part. (4) Engages in any practice that could reasonably be expected to have the effect of denying or discouraging enrollment of individuals whose medical condition or history indicates a need for substantial future medical services. (5) Misrepresents or falsifies information that it furnishes— (i) To CMS; or (ii) To an individual or to any other entity. (6) Fails to comply with the requirements of §422.206, which prohibits interference with practitioners' advice to enrollees. (7) Fails to comply with §422.216, which requires the organization to enforce the limit on balance billing under a private fee-for service plan. (8) Employs or contracts with an individual or entity who is excluded from participation in Medicare under section 1128 or 1128A of the Act (or with an entity that employs or contracts with such an excluded individual or entity) for the provision of any of the following: (i) Health care. (ii) Utilization review. (iii) Medical social work. (iv) Administrative services. (b) Suspension of enrollment and marketing. If CMS makes a determination under §422.510(a), CMS may impose the intermediate sanctions in §422.750(a)(2) and (a)(4). [63 FR 35115, June 26, 1998; 63 FR 52614, Oct. 1, 1998, as amended at 69 FR 78338, Dec. 30, 2004; 70 FR 4741, Jan. 28, 2005; 70 FR 52027, Sept. 1, 2005]
Title 42: Public Health
PART 422—MEDICARE ADVANTAGE PROGRAM
Subpart O—Intermediate Sanctions
§ 422.752 Basis for imposing sanctions.
