[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: 42CFR422.205]



[Page 1013-1014]

 

                         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 E_Relationships With Providers

 

Sec. 422.205  Provider antidiscrimination rules.



    (a) General rule. Consistent with the requirements of this section, 

the policies and procedures concerning provider selection and 

credentialing established under Sec. 422.204, and with the requirement 

under Sec. 422.100(c) that all Medicare-covered services be available 

to MA plan enrollees, an MA organization may select the practitioners 

that participate in its plan provider networks. In selecting these 

practitioners, an MA organization may not discriminate, in terms of 

participation, reimbursement, or indemnification, against any health 

care professional who is acting within the scope of his or her license 

or certification under State law, solely on the basis of the license or 

certification. If an MA organization declines to include a given 

provider or group of providers in its network, it must furnish written 

notice to the effected provider(s) of the reason for the decision.

    (b) Construction. The prohibition in paragraph (a)(1) of this 

section does not preclude any of the following by the MA organization:

    (1) Refusal to grant participation to health care professionals in 

excess of the number necessary to meet the needs of the plan's enrollees 

(except for MA private-fee-for-service plans, which may not refuse to 

contract on this basis).

    (2) Use of different reimbursement amounts for different specialties 

or for different practitioners in the same specialty.

    (3) Implementation of measures designed to maintain quality and 

control



[[Page 1014]]



costs consistent with its responsibilities.



[65 FR 40324, June 29, 2000]