[Code of Federal Regulations] [Title 42, Volume 2] [Revised as of October 1, 2005] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR422.1] [Page 969-971] TITLE 42--PUBLIC HEALTH CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES PART 422_MEDICARE ADVANTAGE PROGRAM--Table of Contents Subpart A_General Provisions Sec. 422.1 Basis and scope. Subpart A_General Provisions Sec. 422.1 Basis and scope. 422.2 Definitions. 422.4 Types of MA plans. 422.6 Cost-sharing in enrollment-related costs. Subpart B_Eligibility, Election, and Enrollment 422.50 Eligibility to elect an MA plan. 422.52 Eligibility to elect an MA plan for special needs individuals. 422.54 Continuation of enrollment for MA local plans. 422.56 Limitations on enrollment in an MA MSA plan. 422.57 Limited enrollment under MA RFB plans. 422.60 Election process 422.62 Election of coverage under an MA plan. 422.64 Information about the MA program. 422.66 Coordination of enrollment and disenrollment through MA organizations. 422.68 Effective dates of coverage and change of coverage. 422.74 Disenrollment by the MA organization. 422.80 Approval of marketing materials and election forms. Subpart C_Benefits and Beneficiary Protections 422.100 General requirements. 422.101 Requirements relating to basic benefits. 422.102 Supplemental benefits. 422.103 Benefits under an MA MSA plan. 422.104 Special rules on supplemental benefits for MA MSA plans. 422.105 Special rules for self-referral and point of service option. 422.106 Coordination of benefits with employer or union group health plans and Medicaid. 422.108 Medicare secondary payer (MSP) procedures. 422.109 Effect of national coverage determinations (NCDs) and legislative changes in benefits. 422.110 Discrimination against beneficiaries prohibited. 422.111 Disclosure requirements. 422.112 Access to services. 422.113 Special rules for ambulance services, emergency and urgently needed services, and maintenance and post-stabilization care services. 422.114 Access to services under an MA private fee-for-service plan. 422.118 Confidentiality and accuracy of enrollee records. 422.128 Information on advance directives. 422.132 Protection against liability and loss of benefits. 422.133 Return to home skilled nursing facility. Subpart D_Quality Improvement 422.152 Quality improvement program. 422.156 Compliance deemed on the basis of accreditation. 422.157 Accreditation organizations. 422.158 Procedures for approval of accreditation as a basis for deeming compliance. Subpart E_Relationships With Providers 422.200 Basis and scope. 422.202 Participation procedures. 422.204 Provider selection and credentialing. 422.205 Provider antidiscrimination rules. 422.206 Interference with health care professionals' advice to enrollees prohibited. 422.208 Physician incentive plans: requirements and limitations. 422.210 Assurances to CMS. 422.212 Limitations on provider indemnification. 422.214 Special rules for services furnished by noncontract providers. 422.216 Special rules for MA private fee-for-service plans. [[Page 970]] 422.220 Exclusion of services furnished under a private contract. Subpart F_Submission of Bids, Premiums, and Related Information and Plan Approval 422.250 Basis and scope. 422.252 Terminology. 422.254 Submission of bids. 422.256 Review, negotiation, and approval of bids. 422.258 Calculation of benchmarks. 422.262 Beneficiary premiums. 422.264 Calculation of savings. 422.266 Beneficiary rebates. 422.270 Incorrect collections of premiums and cost sharing. Subpart G_Payments to Medicare Advantage Organizations 422.300 Basis and scope. 422.304 Monthly payments. 422.306 Annual MA capitation rates. 422.308 Adjustments to capitation rates, benchmarks, bids, and payments. 422.310 Risk adjustment data. 422.311 Announcement of annual capitation rate, benchmarks, and methodology changes. 422.314 Special rules for beneficiaries enrolled in MA MSA plans. 422.316 Special rules for payments to Federally qualified health centers. 422.318 Special rules for coverage that begins or ends during an inpatient hospital stay. 422.320 Special rules for hospice care. 422.322 Source of payment and effect of MA plan election on payment. 422.324 Payments to MA organizations for graduate medical education costs. Subpart H_Provider-Sponsored Organizations 422.350 Basis, scope, and definitions. 422.352 Basic requirements. 422.354 Requirements for affiliated providers. 422.356 Determining substantial financial risk and majority financial interest. 422.370 Waiver of State licensure. 422.372 Basis for waiver of State licensure. 422.374 Waiver request and approval process. 422.376 Conditions of the waiver. 422.378 Relationship to State law. 422.380 Solvency standards. 422.382 Minimum net worth amount. 422.384 Financial plan requirement. 422.386 Liquidity. 422.388 Deposits. 422.390 Guarantees. Subpart I_Organization Compliance With State Law and Preemption by Federal Law 422.400 State licensure requirement. 422.402 Federal preemption of State law. 422.404 State premium taxes prohibited. Subpart J_Special Rules for MA Regional Plans 422.451 Moratorium on new local preferred provider organization plans. 422.455 Special rules for MA Regional plans. 422.458 Risk sharing with regional MA organizations for 2006 and 2007. Subpart K_Contracts With Medicare Advantage Organizations 422.500 Scope and definitions. 422.501 Application requirements. 422.502 Evaluation and determination procedures. 422.503 General provisions. 422.504 Contract provisions. 422.505 Effective date and term of contract. 422.506 Nonrenewal of contract. 422.508 Modification or termination of contract by mutual consent. 422.510 Termination of contract by CMS. 422.512 Termination of contract by the MA organization. 422.514 Minimum enrollment requirements. 422.516 Reporting requirements. 422.520 Prompt payment by MA organization. 422.521 Effective date of new significant regulatory requirements. 422.524 Special rules for RFB societies. 422.527 Agreements with Federally qualified health centers. Subpart L_Effect of Change of Ownership or Leasing of Facilities During Term of Contract 422.550 General provisions. 422.552 Novation agreement requirements. 422.553 Effect of leasing of an MA organization's facilities. Subpart M_Grievances, Organization Determinations and Appeals 422.560 Basis and scope. 422.561 Definitions. 422.562 General provisions. 422.564 Grievance procedures. 422.566 Organization determinations. 422.568 Standard timeframes and notice requirements for organization determinations. 422.570 Expediting certain organization determinations. 422.572 Timeframes and notice requirements for expedited organization determinations. [[Page 971]] 422.574 Parties to the organization determination. 422.576 Effect of an organization determination. 422.578 Right to a reconsideration. 422.580 Reconsideration defined. 422.582 Request for a standard reconsideration. 422.584 Expediting certain reconsiderations. 422.586 Opportunity to submit evidence. 422.590 Timeframes and responsibility for reconsiderations. 422.592 Reconsideration by an independent entity. 422.594 Notice of reconsidered determination by the independent entity. 422.596 Effect of a reconsidered determination. 422.600 Right to a hearing. 422.602 Request for an ALJ hearing. 422.608 Medicare Appeals Council (MAC) review. 422.612 Judicial review. 422.616 Reopening and revising determinations and decisions. 422.618 How an MA organization must effectuate standard reconsidered determinations or decisions. 422.619 How an MA organization must effectuate expedited reconsidered determinations. 422.620 How enrollees of MA organizations must be notified of noncovered inpatient hospital care. 422.622 Requesting immediate QIO review of noncoverage of inpatient hospital care. 422.624 Notifying enrollees of termination of provider services. 422.626 Fast-track appeals of service terminations to independent review entities (IREs). Subpart N_Medicare Contract Determinations and Appeals 422.641 Contract determinations. 422.644 Notice of contract determination. 422.646 Effect of contract determination. 422.648 Reconsideration: Applicability. 422.650 Request for reconsideration. 422.652 Opportunity to submit evidence. 422.654 Reconsidered determination. 422.656 Notice of reconsidered determination. 422.658 Effect of reconsidered determination. 422.660 Right to a hearing. 422.662 Request for hearing. 422.664 Postponement of effective date of a contract determination when a request for a hearing with respect to a contract determination is filed timely. 422.666 Designation of hearing officer. 422.668 Disqualification of hearing officer. 422.670 Time and place of hearing. 422.672 Appointment of representatives. 422.674 Authority of representatives. 422.676 Conduct of hearing. 422.678 Evidence. 422.680 Witnesses. 422.682 Discovery. 422.684 Prehearing. 422.686 Record of hearing. 422.688 Authority of hearing officer. 422.690 Notice and effect of hearing decision. 422.692 Review by the Administrator. 422.694 Effect of Administrator's decision. 422.696 Reopening of contract or reconsidered determination or decision of a hearing officer or the Administrator. 422.698 Effect of revised determination. Subpart O_Intermediate Sanctions 422.750 Kinds of sanctions. 422.752 Basis for imposing sanctions. 422.756 Procedures for imposing sanctions. 422.758 Maximum amount of civil money penalties imposed by CMS. 422.760 Other applicable provisions. Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). Source: 63 FR 18134, Apr. 14, 1998, unless otherwise noted. Editorial Note; Nomenclature changes to part 422 appear at 70 FR 4741, Jan. 28, 2005. Source: 63 FR 35068, June 26, 1998, unless otherwise noted. (a) Basis. This part is based on the indicated provisions of the following sections of the Act: 1851--Eligibility, election, and enrollment. 1852--Benefits and beneficiary protections. 1853--Payments to Medicare Advantage (MA) organizations. 1854--Premiums. 1855--Organization, licensure, and solvency of MA organizations. 1856--Standards. 1857--Contract requirements. 1858--Special rules for MA Regional Plans. 1859--Definitions; enrollment restriction for certain MA plans. (b) Scope. This part establishes standards and sets forth the requirements, limitations, and procedures for Medicare services furnished, or paid for, by Medicare Advantage organizations through Medicare Advantage plans. [63 FR 35068, June 26, 1998, as amended at 70 FR 4714, Jan. 28, 2005] [[Page 972]]