[Code of Federal Regulations]
[Title 42, Volume 2]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR422.210]

[Page 871]
 
                         TITLE 42--PUBLIC HEALTH
 
                             HUMAN SERVICES
 
PART 422--MEDICARE+CHOICE PROGRAM--Table of Contents
 
                 Subpart E--Relationships With Providers
 
Sec. 422.210  Disclosure of physician incentive plans

    (a) Disclosure to CMS--(1) Basic requirement. Each M+C organization 
must provide to CMS descriptive information about its physician 
incentive plan in sufficient detail to enable CMS to determine whether 
that plan complies with the requirements of Sec. 422.208. Reporting 
should be on the CMS PIP Disclosure Form (OMB No. 0938-0700).
    (2) Content. The information must include at least the following:
    (i) Whether services not furnished by the physician or physician 
group are covered by the incentive plan.
    (ii) The type or types of incentive arrangements, such as, 
withholds, bonus, capitation.
    (iii) The percent of any withhold or bonus the plan uses.
    (iv) Assurance that the physicians or physician group has adequate 
stop-loss protection, and the amount and type of stop-loss protection.
    (v) The patient panel size and, if the plan uses pooling, the 
pooling method.
    (vi) If the M+C organization is required to conduct enrollee 
surveys, a summary of the survey results.
    (3) When disclosure must be made to CMS. An M+C organization must 
disclose annually to CMS the physician incentive arrangements that are 
effective at the start of each year. In addition, CMS does not approve 
an M+C organization's application for a contract unless the M+C 
organization discloses the physician incentive arrangements effective 
for that contract.
    (b) Disclosure to Medicare beneficiaries--Basic requirement. An M+C 
organization must provide the following information to any Medicare 
beneficiary who requests it:
    (1) Whether the M+C organization uses a physician incentive plan 
that affects the use of referral services.
    (2) The type of incentive arrangement.
    (3) Whether stop-loss protection is provided.
    (4) If the M+C organization was required to conduct a survey, a 
summary of the survey results.