42 CFR Part 422
PART 422—MEDICARE ADVANTAGE PROGRAM
- PART 422—MEDICARE ADVANTAGE PROGRAM
- Chapter IV—Centers for Medicare & Medicaid Services, Department of Health and Human Services › Subchapter B—Medicare Program
- Subpart A—General Provisions
- § 422.1 Basis and scope.
- § 422.2 Definitions.
- § 422.3 MA organizations' use of reinsurance.
- § 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.
- § 422.53 Eligibility to elect an MA plan for senior housing facility residents.
- § 422.54 Continuation of enrollment for MA local plans.
- § 422.56 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.
- 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.
- § 422.107 Requirements for dual eligible special needs plans.
- § 422.108 Medicare secondary payer (MSP) procedures.
- § 422.109 Effect of national coverage determinations (NCDs) and legislative changes in benefits; coverage of clinical trials and A and B device trials.
- § 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.
- § 422.116 Network adequacy.
- § 422.118 Confidentiality and accuracy of enrollee records.
- § 422.119 Access to and exchange of health data and plan information.
- § 422.120 Access to published provider directory information.
- § 422.121 Access to and exchange of health data for providers and payers.
- § 422.122 Prior authorization requirements.
- § 422.125 Resolution of complaints in a Complaints Tracking Module.
- § 422.128 Information on advance directives.
- § 422.132 Protection against liability and loss of benefits.
- § 422.133 Return to home skilled nursing facility.
- § 422.134 Reward and incentive programs.
- § 422.135 Additional telehealth benefits.
- § 422.136 Medicare Advantage (MA) and step therapy for Part B drugs.
- § 422.137 Medicare Advantage Utilization Management Committee.
- § 422.138 Prior authorization.
- Subpart D—Quality Improvement
- § 422.152 Quality improvement program.
- § 422.153 Use of quality improvement organization review information.
- § 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.
- § 422.160 Basis and scope of the Medicare Advantage Quality Rating System.
- § 422.162 Medicare Advantage Quality Rating System.
- § 422.164 Adding, updating, and removing measures.
- § 422.166 Calculation of Star Ratings.
- 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.
- § 422.220 Exclusion of payment for basic benefits furnished under a private contract.
- § 422.222 Preclusion list for contracted and non-contracted individuals and entities.
- § 422.224 Payment to individuals and entities excluded by the OIG or included on the preclusion list.
- 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.
- § 422.260 Appeals of quality bonus payment determinations.
- § 422.262 Beneficiary premiums.
- § 422.264 Calculation of savings.
- § 422.266 Beneficiary rebates.
- § 422.270 Incorrect collections of premiums and cost-sharing.
- § 422.272 Release of MA bid pricing data.
- 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 RADV audit dispute and appeal processes.
- § 422.312 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.
- § 422.326 Reporting and returning of overpayments.
- § 422.330 CMS-identified overpayments associated with payment data submitted by MA organizations.
- 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—Application Procedures and Contracts for 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 Enrollment requirements.
- § 422.516 Validation of Part C 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.
- § 422.528 Final settlement process and payment.
- § 422.529 Requesting an appeal of the final settlement amount.
- § 422.530 Plan crosswalks.
- 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.
- § 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 (Council) 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 Notifying enrollees of hospital discharge appeal rights.
- § 422.622 Requesting immediate QIO review of the decision to discharge from the inpatient hospital.
- § 422.624 Notifying enrollees of termination of provider services.
- § 422.626 Fast-track appeals of service terminations to independent review entities (IREs).
- Requirements Applicable to Certain Integrated Dual Eligible Special Needs Plans
- § 422.629 General requirements for applicable integrated plans.
- § 422.630 Integrated grievances.
- § 422.631 Integrated organization determinations.
- § 422.632 Continuation of benefits while the applicable integrated plan reconsideration is pending.
- § 422.633 Integrated reconsiderations.
- § 422.634 Effect.
- Subpart N—Medicare Contract Determinations and Appeals
- § 422.641 Contract determinations.
- § 422.644 Notice of contract determination.
- § 422.646 Effect of contract determination.
- § 422.660 Right to a hearing, burden of proof, standard of proof, and standards of review.
- § 422.662 Request for hearing.
- § 422.664 Postponement of effective date of a contract determination when a request for a hearing 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 Witness lists and documents.
- § 422.684 Prehearing and summary judgment.
- § 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 a contract determination or decision of a hearing officer or the Administrator.
- Subpart O—Intermediate Sanctions
- § 422.750 Types of intermediate sanctions and civil money penalties.
- § 422.752 Basis for imposing intermediate sanctions and civil money penalties.
- § 422.756 Procedures for imposing intermediate sanctions and civil money penalties.
- § 422.758 Collection of civil money penalties imposed by CMS.
- § 422.760 Determinations regarding the amount of civil money penalties and assessment imposed by CMS.
- § 422.762 Settlement of penalties.
- § 422.764 Other applicable provisions.
- Subparts P-S [Reserved]
- Subpart T—Appeal procedures for Civil Money Penalties
- § 422.1000 Basis and scope.
- § 422.1002 Definitions.
- § 422.1004 Scope and applicability.
- § 422.1006 Appeal rights.
- § 422.1008 Appointment of representatives.
- § 422.1010 Authority of representatives.
- § 422.1012 Fees for services of representatives.
- § 422.1014 Charge for transcripts.
- § 422.1016 Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal.
- § 422.1018 Notice and effect of initial determinations.
- § 422.1020 Request for hearing.
- § 422.1022 Parties to the hearing.
- § 422.1024 Designation of hearing official.
- § 422.1026 Disqualification of Administrative Law Judge.
- § 422.1028 Prehearing conference.
- § 422.1030 Notice of prehearing conference.
- § 422.1032 Conduct of prehearing conference.
- § 422.1034 Record, order, and effect of prehearing conference.
- § 422.1036 Time and place of hearing.
- § 422.1038 Change in time and place of hearing.
- § 422.1040 Joint hearings.
- § 422.1042 Hearing on new issues.
- § 422.1044 Subpoenas.
- § 422.1046 Conduct of hearing.
- § 422.1048 Evidence.
- § 422.1050 Witnesses.
- § 422.1052 Oral and written summation.
- § 422.1054 Record of hearing.
- § 422.1056 Waiver of right to appear and present evidence.
- § 422.1058 Dismissal of request for hearing.
- § 422.1060 Dismissal for abandonment.
- § 422.1062 Dismissal for cause.
- § 422.1064 Notice and effect of dismissal and right to request review.
- § 422.1066 Vacating a dismissal of request for hearing.
- § 422.1068 Administrative Law Judge's decision.
- § 422.1070 Removal of hearing to Departmental Appeals Board.
- § 422.1072 Remand by the Administrative Law Judge.
- § 422.1074 Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal.
- § 422.1076 Request for Departmental Appeals Board review.
- § 422.1078 Departmental Appeals Board action on request for review.
- § 422.1080 Procedures before the Departmental Appeals Board on review.
- § 422.1082 Evidence admissible on review.
- § 422.1084 Decision or remand by the Departmental Appeals Board.
- § 422.1086 Effect of Departmental Appeals Board Decision.
- § 422.1088 Extension of time for seeking judicial review.
- § 422.1090 Basis, timing, and authority for reopening an Administrative Law Judge or Board decision.
- § 422.1092 Revision of reopened decision.
- § 422.1094 Notice and effect of revised decision.
- Subpart U [Reserved]
- Subpart V—Medicare Advantage Communication Requirements
- § 422.2260 Definitions.
- § 422.2261 Submission, review, and distribution of materials.
- § 422.2262 General communications materials and activities requirements.
- § 422.2263 General marketing requirements.
- § 422.2264 Beneficiary contact.
- § 422.2265 Websites.
- § 422.2266 Activities with healthcare providers or in the healthcare setting.
- § 422.2267 Required materials and content.
- § 422.2272 Licensing of marketing representatives and confirmation of marketing resources.
- § 422.2274 Agent, broker, and other third-party requirements.
- § 422.2276 Employer group retiree marketing.
- Subpart W [Reserved]
- Subpart X—Requirements for a Minimum Medical Loss Ratio
- § 422.2400 Basis and scope.
- § 422.2401 Definitions.
- § 422.2410 General requirements.
- § 422.2420 Calculation of the medical loss ratio.
- § 422.2430 Activities that improve health care quality.
- § 422.2440 Credibility adjustment.
- § 422.2450 [Reserved]
- § 422.2460 Reporting requirements.
- § 422.2470 Remittance to CMS if the applicable MLR requirement is not met.
- § 422.2480 MLR review and non-compliance.
- § 422.2490 Release of Part C MLR data.
- Subpart Y [Reserved]
- Subpart Z—Part C Recovery Audit Contractor Appeals Process
- § 422.2600 Payment appeals.
- § 422.2605 Request for reconsideration.
- § 422.2610 Hearing official review.
- § 422.2615 Review by the Administrator.
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