Title 42, Part 422 — Medicare Advantage Program

Basis and scope.

Definitions.

MA organizations' use of reinsurance.

Types of MA plans.

Cost-sharing in enrollment-related costs.

Eligibility to elect an MA plan.

Eligibility to elect an MA plan for special needs individuals.

Eligibility to elect an MA plan for senior housing facility residents.

Continuation of enrollment for MA local plans.

Enrollment in an MA MSA plan.

Limited enrollment under MA RFB plans.

Election process.

Election of coverage under an MA plan.

Information about the MA program.

Coordination of enrollment and disenrollment through MA organizations.

Effective dates of coverage and change of coverage.

Disenrollment by the MA organization.

General requirements.

Requirements relating to basic benefits.

Supplemental benefits.

Benefits under an MA MSA plan.

Special rules on supplemental benefits for MA MSA plans.

Special rules for self-referral and point of service option.

Coordination of benefits with employer or union group health plans and Medicaid.

Requirements for dual eligible special needs plans.

Medicare secondary payer (MSP) procedures.

Effect of national coverage determinations (NCDs) and legislative changes in benefits; coverage of clinical trials and A and B device trials.

Discrimination against beneficiaries prohibited.

Disclosure requirements.

Access to services.

Special rules for ambulance services, emergency and urgently needed services, and maintenance and post-stabilization care services.

Access to services under an MA private fee-for-service plan.

Network adequacy.

Confidentiality and accuracy of enrollee records.

Access to and exchange of health data and plan information.

Access to published provider directory information.

Access to and exchange of health data for providers and payers.

Prior authorization requirements.

Resolution of complaints in a Complaints Tracking Module.

Information on advance directives.

Protection against liability and loss of benefits.

Return to home skilled nursing facility.

Reward and incentive programs.

Additional telehealth benefits.

Medicare Advantage (MA) and step therapy for Part B drugs.

Medicare Advantage Utilization Management Committee.

Prior authorization.

Quality improvement program.

Use of quality improvement organization review information.

Compliance deemed on the basis of accreditation.

Accreditation organizations.

Procedures for approval of accreditation as a basis for deeming compliance.

Basis and scope of the Medicare Advantage Quality Rating System.

Medicare Advantage Quality Rating System.

Adding, updating, and removing measures.

Calculation of Star Ratings.

Basis and scope.

Participation procedures.

Provider selection and credentialing.

Provider antidiscrimination rules.

Interference with health care professionals' advice to enrollees prohibited.

Physician incentive plans: requirements and limitations.

Assurances to CMS.

Limitations on provider indemnification.

Special rules for services furnished by noncontract providers.

Special rules for MA private fee-for-service plans.

Exclusion of payment for basic benefits furnished under a private contract.

Preclusion list for contracted and non-contracted individuals and entities.

Payment to individuals and entities excluded by the OIG or included on the preclusion list.

Basis and scope.

Terminology.

Submission of bids.

Review, negotiation, and approval of bids.

Calculation of benchmarks.

Appeals of quality bonus payment determinations.

Beneficiary premiums.

Calculation of savings.

Beneficiary rebates.

Incorrect collections of premiums and cost-sharing.

Release of MA bid pricing data.

Basis and scope.

Monthly payments.

Annual MA capitation rates.

Adjustments to capitation rates, benchmarks, bids, and payments.

Risk adjustment data.

RADV audit dispute and appeal processes.

Announcement of annual capitation rate, benchmarks, and methodology changes.

Special rules for beneficiaries enrolled in MA MSA plans.

Special rules for payments to Federally qualified health centers.

Special rules for coverage that begins or ends during an inpatient hospital stay.

Special rules for hospice care.

Source of payment and effect of MA plan election on payment.

Payments to MA organizations for graduate medical education costs.

Reporting and returning of overpayments.

CMS-identified overpayments associated with payment data submitted by MA organizations.

Basis, scope, and definitions.

Basic requirements.

Requirements for affiliated providers.

Determining substantial financial risk and majority financial interest.

Waiver of State licensure.

Basis for waiver of State licensure.

Waiver request and approval process.

Conditions of the waiver.

Relationship to State law.

Solvency standards.

Minimum net worth amount.

Financial plan requirement.

Liquidity.

Deposits.

Guarantees.

State licensure requirement.

Federal preemption of State law.

State premium taxes prohibited.

Moratorium on new local preferred provider organization plans.

Special rules for MA Regional Plans.

Risk sharing with regional MA organizations for 2006 and 2007.

Scope and definitions.

Application requirements.

Evaluation and determination procedures.

General provisions.

Contract provisions.

Effective date and term of contract.

Nonrenewal of contract.

Modification or termination of contract by mutual consent.

Termination of contract by CMS.

Termination of contract by the MA organization.

Enrollment requirements.

Validation of Part C reporting requirements.

Prompt payment by MA organization.

Effective date of new significant regulatory requirements.

Special rules for RFB societies.

Agreements with Federally qualified health centers.

Final settlement process and payment.

Requesting an appeal of the final settlement amount.

Plan crosswalks.

General provisions.

Novation agreement requirements.

Effect of leasing of an MA organization's facilities.

Basis and scope.

Definitions.

General provisions.

Grievance procedures.

Organization determinations.

Standard timeframes and notice requirements for organization determinations.

Expediting certain organization determinations.

Timeframes and notice requirements for expedited organization determinations.

Parties to the organization determination.

Effect of an organization determination.

Right to a reconsideration.

Reconsideration defined.

Request for a standard reconsideration.

Expediting certain reconsiderations.

Opportunity to submit evidence.

Timeframes and responsibility for reconsiderations.

Reconsideration by an independent entity.

Notice of reconsidered determination by the independent entity.

Effect of a reconsidered determination.

Right to a hearing.

Request for an ALJ hearing.

Medicare Appeals Council (Council) review.

Judicial review.

Reopening and revising determinations and decisions.

How an MA organization must effectuate standard reconsidered determinations or decisions.

How an MA organization must effectuate expedited reconsidered determinations.

Notifying enrollees of hospital discharge appeal rights.

Requesting immediate QIO review of the decision to discharge from the inpatient hospital.

Notifying enrollees of termination of provider services.

Fast-track appeals of service terminations to independent review entities (IREs).

General requirements for applicable integrated plans.

Integrated grievances.

Integrated organization determinations.

Continuation of benefits while the applicable integrated plan reconsideration is pending.

Integrated reconsiderations.

Effect.

Contract determinations.

Notice of contract determination.

Effect of contract determination.

Right to a hearing, burden of proof, standard of proof, and standards of review.

Request for hearing.

Postponement of effective date of a contract determination when a request for a hearing is filed timely.

Designation of hearing officer.

Disqualification of hearing officer.

Time and place of hearing.

Appointment of representatives.

Authority of representatives.

Conduct of hearing.

Evidence.

Witnesses.

Witness lists and documents.

Prehearing and summary judgment.

Record of hearing.

Authority of hearing officer.

Notice and effect of hearing decision.

Review by the Administrator.

Effect of Administrator's decision.

Reopening of a contract determination or decision of a hearing officer or the Administrator.

Types of intermediate sanctions and civil money penalties.

Basis for imposing intermediate sanctions and civil money penalties.

Procedures for imposing intermediate sanctions and civil money penalties.

Collection of civil money penalties imposed by CMS.

Determinations regarding the amount of civil money penalties and assessment imposed by CMS.

Settlement of penalties.

Other applicable provisions.

Basis and scope.

Definitions.

Scope and applicability.

Appeal rights.

Appointment of representatives.

Authority of representatives.

Fees for services of representatives.

Charge for transcripts.

Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal.

Notice and effect of initial determinations.

Request for hearing.

Parties to the hearing.

Designation of hearing official.

Disqualification of Administrative Law Judge.

Prehearing conference.

Notice of prehearing conference.

Conduct of prehearing conference.

Record, order, and effect of prehearing conference.

Time and place of hearing.

Change in time and place of hearing.

Joint hearings.

Hearing on new issues.

Subpoenas.

Conduct of hearing.

Evidence.

Witnesses.

Oral and written summation.

Record of hearing.

Waiver of right to appear and present evidence.

Dismissal of request for hearing.

Dismissal for abandonment.

Dismissal for cause.

Notice and effect of dismissal and right to request review.

Vacating a dismissal of request for hearing.

Administrative Law Judge's decision.

Removal of hearing to Departmental Appeals Board.

Remand by the Administrative Law Judge.

Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal.

Request for Departmental Appeals Board review.

Departmental Appeals Board action on request for review.

Procedures before the Departmental Appeals Board on review.

Evidence admissible on review.

Decision or remand by the Departmental Appeals Board.

Effect of Departmental Appeals Board Decision.

Extension of time for seeking judicial review.

Basis, timing, and authority for reopening an Administrative Law Judge or Board decision.

Revision of reopened decision.

Notice and effect of revised decision.

Definitions.

Submission, review, and distribution of materials.

General communications materials and activities requirements.

General marketing requirements.

Beneficiary contact.

Websites.

Activities with healthcare providers or in the healthcare setting.

Required materials and content.

Licensing of marketing representatives and confirmation of marketing resources.

Agent, broker, and other third-party requirements.

Employer group retiree marketing.

Basis and scope.

Definitions.

General requirements.

Calculation of the medical loss ratio.

Activities that improve health care quality.

Credibility adjustment.

[Reserved]

Reporting requirements.

Remittance to CMS if the applicable MLR requirement is not met.

MLR review and non-compliance.

Release of Part C MLR data.

Payment appeals.

Request for reconsideration.

Hearing official review.

Review by the Administrator.