42 C.F.R. PART 422--MEDICARE ADVANTAGE PROGRAM
TITLE 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B--MEDICARE PROGRAM
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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| 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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| Approval of marketing materials and election forms.
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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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| 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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| 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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Subpart D--QUALITY IMPROVEMENT
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| Quality improvement program.
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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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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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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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| Incorrect collections of premiums and cost-sharing.
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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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| 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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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--CONTRACTS WITH 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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| 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 (MAC) 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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| How enrollees of MA organizations must be notified of noncovered inpatient hospital care.
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| Requesting immediate QIO review of noncoverage of inpatient hospital care.
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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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| Reconsideration: Applicability.
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| Request for reconsideration.
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| Opportunity to submit evidence.
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| Reconsidered determination.
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| Notice of reconsidered determination.
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| Effect of reconsidered determination.
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| Postponement of effective date of a contract determination when a request for a hearing with respect to a contract determination 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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| 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 contract or reconsidered determination or decision of a hearing officer or the Administrator.
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| Effect of revised determination.
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Subpart O--INTERMEDIATE SANCTIONS
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| Basis for imposing sanctions.
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| Procedures for imposing sanctions.
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| Maximum amount of civil money penalties imposed by CMS.
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| Other applicable provisions.
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