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FEDERAL · 42 CFR

Part 422 — Medicare Advantage Program

277 sections · Title 42: Public Health

§ 422.1Basis and scope.
§ 422.2Definitions.
§ 422.3MA organizations' use of reinsurance.
§ 422.4Types of MA plans.
§ 422.6Cost-sharing in enrollment-related costs.
§ 422.50Eligibility to elect an MA plan.
§ 422.52Eligibility to elect an MA plan for special needs individuals.
§ 422.53Eligibility to elect an MA plan for senior housing facility residents.
§ 422.54Continuation of enrollment for MA local plans.
§ 422.56Enrollment in an MA MSA plan.
§ 422.57Limited enrollment under MA RFB plans.
§ 422.60Election process.
§ 422.62Election of coverage under an MA plan.
§ 422.64Information about the MA program.
§ 422.66Coordination of enrollment and disenrollment through MA organizations.
§ 422.68Effective dates of coverage and change of coverage.
§ 422.74Disenrollment by the MA organization.
§ 422.100General requirements.
§ 422.101Requirements relating to basic benefits.
§ 422.102Supplemental benefits.
§ 422.103Benefits under an MA MSA plan.
§ 422.104Special rules on supplemental benefits for MA MSA plans.
§ 422.105Special rules for self-referral and point of service option.
§ 422.106Coordination of benefits with employer or union group health plans and Medicaid.
§ 422.107Requirements for dual eligible special needs plans.
§ 422.108Medicare secondary payer (MSP) procedures.
§ 422.109Effect of national coverage determinations (NCDs) and legislative changes in benefits; coverage of clinical trials and A and B device trials.
§ 422.110Discrimination against beneficiaries prohibited.
§ 422.111Disclosure requirements.
§ 422.112Access to services.
§ 422.113Special rules for ambulance services, emergency and urgently needed services, and maintenance and post-stabilization care services.
§ 422.114Access to services under an MA private fee-for-service plan.
§ 422.116Network adequacy.
§ 422.118Confidentiality and accuracy of enrollee records.
§ 422.119Access to and exchange of health data and plan information.
§ 422.120Access to published provider directory information.
§ 422.121Access to and exchange of health data for providers and payers.
§ 422.122Prior authorization requirements.
§ 422.125Resolution of complaints in a Complaints Tracking Module.
§ 422.128Information on advance directives.
§ 422.132Protection against liability and loss of benefits.
§ 422.133Return to home skilled nursing facility.
§ 422.134Reward and incentive programs.
§ 422.135Additional telehealth benefits.
§ 422.136Medicare Advantage (MA) and step therapy for Part B drugs.
§ 422.137Medicare Advantage Utilization Management Committee.
§ 422.138Prior authorization.
§ 422.152Quality improvement program.
§ 422.153Use of quality improvement organization review information.
§ 422.156Compliance deemed on the basis of accreditation.
§ 422.157Accreditation organizations.
§ 422.158Procedures for approval of accreditation as a basis for deeming compliance.
§ 422.160Basis and scope of the Medicare Advantage Quality Rating System.
§ 422.162Medicare Advantage Quality Rating System.
§ 422.164Adding, updating, and removing measures.
§ 422.166Calculation of Star Ratings.
§ 422.200Basis and scope.
§ 422.202Participation procedures.
§ 422.204Provider selection and credentialing.
§ 422.205Provider antidiscrimination rules.
§ 422.206Interference with health care professionals' advice to enrollees prohibited.
§ 422.208Physician incentive plans: requirements and limitations.
§ 422.210Assurances to CMS.
§ 422.212Limitations on provider indemnification.
§ 422.214Special rules for services furnished by noncontract providers.
§ 422.216Special rules for MA private fee-for-service plans.
§ 422.220Exclusion of payment for basic benefits furnished under a private contract.
§ 422.222Preclusion list for contracted and non-contracted individuals and entities.
§ 422.224Payment to individuals and entities excluded by the OIG or included on the preclusion list.
§ 422.250Basis and scope.
§ 422.252Terminology.
§ 422.254Submission of bids.
§ 422.256Review, negotiation, and approval of bids.
§ 422.258Calculation of benchmarks.
§ 422.260Appeals of quality bonus payment determinations.
§ 422.262Beneficiary premiums.
§ 422.264Calculation of savings.
§ 422.266Beneficiary rebates.
§ 422.270Incorrect collections of premiums and cost-sharing.
§ 422.272Release of MA bid pricing data.
§ 422.300Basis and scope.
§ 422.304Monthly payments.
§ 422.306Annual MA capitation rates.
§ 422.308Adjustments to capitation rates, benchmarks, bids, and payments.
§ 422.310Risk adjustment data.
§ 422.311RADV audit dispute and appeal processes.
§ 422.312Announcement of annual capitation rate, benchmarks, and methodology changes.
§ 422.314Special rules for beneficiaries enrolled in MA MSA plans.
§ 422.316Special rules for payments to Federally qualified health centers.
§ 422.318Special rules for coverage that begins or ends during an inpatient hospital stay.
§ 422.320Special rules for hospice care.
§ 422.322Source of payment and effect of MA plan election on payment.
§ 422.324Payments to MA organizations for graduate medical education costs.
§ 422.326Reporting and returning of overpayments.
§ 422.330CMS-identified overpayments associated with payment data submitted by MA organizations.
§ 422.350Basis, scope, and definitions.
§ 422.352Basic requirements.
§ 422.354Requirements for affiliated providers.
§ 422.356Determining substantial financial risk and majority financial interest.
§ 422.370Waiver of State licensure.
§ 422.372Basis for waiver of State licensure.
§ 422.374Waiver request and approval process.
§ 422.376Conditions of the waiver.
§ 422.378Relationship to State law.
§ 422.380Solvency standards.
§ 422.382Minimum net worth amount.
§ 422.384Financial plan requirement.
§ 422.386Liquidity.
§ 422.388Deposits.
§ 422.390Guarantees.
§ 422.400State licensure requirement.
§ 422.402Federal preemption of State law.
§ 422.404State premium taxes prohibited.
§ 422.451Moratorium on new local preferred provider organization plans.
§ 422.455Special rules for MA Regional Plans.
§ 422.458Risk sharing with regional MA organizations for 2006 and 2007.
§ 422.500Scope and definitions.
§ 422.501Application requirements.
§ 422.502Evaluation and determination procedures.
§ 422.503General provisions.
§ 422.504Contract provisions.
§ 422.505Effective date and term of contract.
§ 422.506Nonrenewal of contract.
§ 422.508Modification or termination of contract by mutual consent.
§ 422.510Termination of contract by CMS.
§ 422.512Termination of contract by the MA organization.
§ 422.514Enrollment requirements.
§ 422.516Validation of Part C reporting requirements.
§ 422.520Prompt payment by MA organization.
§ 422.521Effective date of new significant regulatory requirements.
§ 422.524Special rules for RFB societies.
§ 422.527Agreements with Federally qualified health centers.
§ 422.528Final settlement process and payment.
§ 422.529Requesting an appeal of the final settlement amount.
§ 422.530Plan crosswalks.
§ 422.550General provisions.
§ 422.552Novation agreement requirements.
§ 422.553Effect of leasing of an MA organization's facilities.
§ 422.560Basis and scope.
§ 422.561Definitions.
§ 422.562General provisions.
§ 422.564Grievance procedures.
§ 422.566Organization determinations.
§ 422.568Standard timeframes and notice requirements for organization determinations.
§ 422.570Expediting certain organization determinations.
§ 422.572Timeframes and notice requirements for expedited organization determinations.
§ 422.574Parties to the organization determination.
§ 422.576Effect of an organization determination.
§ 422.578Right to a reconsideration.
§ 422.580Reconsideration defined.
§ 422.582Request for a standard reconsideration.
§ 422.584Expediting certain reconsiderations.
§ 422.586Opportunity to submit evidence.
§ 422.590Timeframes and responsibility for reconsiderations.
§ 422.592Reconsideration by an independent entity.
§ 422.594Notice of reconsidered determination by the independent entity.
§ 422.596Effect of a reconsidered determination.
§ 422.600Right to a hearing.
§ 422.602Request for an ALJ hearing.
§ 422.608Medicare Appeals Council (Council) review.
§ 422.612Judicial review.
§ 422.616Reopening and revising determinations and decisions.
§ 422.618How an MA organization must effectuate standard reconsidered determinations or decisions.
§ 422.619How an MA organization must effectuate expedited reconsidered determinations.
§ 422.620Notifying enrollees of hospital discharge appeal rights.
§ 422.622Requesting immediate QIO review of the decision to discharge from the inpatient hospital.
§ 422.624Notifying enrollees of termination of provider services.
§ 422.626Fast-track appeals of service terminations to independent review entities (IREs).
§ 422.629General requirements for applicable integrated plans.
§ 422.630Integrated grievances.
§ 422.631Integrated organization determinations.
§ 422.632Continuation of benefits while the applicable integrated plan reconsideration is pending.
§ 422.633Integrated reconsiderations.
§ 422.634Effect.
§ 422.641Contract determinations.
§ 422.644Notice of contract determination.
§ 422.646Effect of contract determination.
§ 422.660Right to a hearing, burden of proof, standard of proof, and standards of review.
§ 422.662Request for hearing.
§ 422.664Postponement of effective date of a contract determination when a request for a hearing is filed timely.
§ 422.666Designation of hearing officer.
§ 422.668Disqualification of hearing officer.
§ 422.670Time and place of hearing.
§ 422.672Appointment of representatives.
§ 422.674Authority of representatives.
§ 422.676Conduct of hearing.
§ 422.678Evidence.
§ 422.680Witnesses.
§ 422.682Witness lists and documents.
§ 422.684Prehearing and summary judgment.
§ 422.686Record of hearing.
§ 422.688Authority of hearing officer.
§ 422.690Notice and effect of hearing decision.
§ 422.692Review by the Administrator.
§ 422.694Effect of Administrator's decision.
§ 422.696Reopening of a contract determination or decision of a hearing officer or the Administrator.
§ 422.750Types of intermediate sanctions and civil money penalties.
§ 422.752Basis for imposing intermediate sanctions and civil money penalties.
§ 422.756Procedures for imposing intermediate sanctions and civil money penalties.
§ 422.758Collection of civil money penalties imposed by CMS.
§ 422.760Determinations regarding the amount of civil money penalties and assessment imposed by CMS.
§ 422.762Settlement of penalties.
§ 422.764Other applicable provisions.
§ 422.1000Basis and scope.
§ 422.1002Definitions.
§ 422.1004Scope and applicability.
§ 422.1006Appeal rights.
§ 422.1008Appointment of representatives.
§ 422.1010Authority of representatives.
§ 422.1012Fees for services of representatives.
§ 422.1014Charge for transcripts.
§ 422.1016Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal.
§ 422.1018Notice and effect of initial determinations.
§ 422.1020Request for hearing.
§ 422.1022Parties to the hearing.
§ 422.1024Designation of hearing official.
§ 422.1026Disqualification of Administrative Law Judge.
§ 422.1028Prehearing conference.
§ 422.1030Notice of prehearing conference.
§ 422.1032Conduct of prehearing conference.
§ 422.1034Record, order, and effect of prehearing conference.
§ 422.1036Time and place of hearing.
§ 422.1038Change in time and place of hearing.
§ 422.1040Joint hearings.
§ 422.1042Hearing on new issues.
§ 422.1044Subpoenas.
§ 422.1046Conduct of hearing.
§ 422.1048Evidence.
§ 422.1050Witnesses.
§ 422.1052Oral and written summation.
§ 422.1054Record of hearing.
§ 422.1056Waiver of right to appear and present evidence.
§ 422.1058Dismissal of request for hearing.
§ 422.1060Dismissal for abandonment.
§ 422.1062Dismissal for cause.
§ 422.1064Notice and effect of dismissal and right to request review.
§ 422.1066Vacating a dismissal of request for hearing.
§ 422.1068Administrative Law Judge's decision.
§ 422.1070Removal of hearing to Departmental Appeals Board.
§ 422.1072Remand by the Administrative Law Judge.
§ 422.1074Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal.
§ 422.1076Request for Departmental Appeals Board review.
§ 422.1078Departmental Appeals Board action on request for review.
§ 422.1080Procedures before the Departmental Appeals Board on review.
§ 422.1082Evidence admissible on review.
§ 422.1084Decision or remand by the Departmental Appeals Board.
§ 422.1086Effect of Departmental Appeals Board Decision.
§ 422.1088Extension of time for seeking judicial review.
§ 422.1090Basis, timing, and authority for reopening an Administrative Law Judge or Board decision.
§ 422.1092Revision of reopened decision.
§ 422.1094Notice and effect of revised decision.
§ 422.2260Definitions.
§ 422.2261Submission, review, and distribution of materials.
§ 422.2262General communications materials and activities requirements.
§ 422.2263General marketing requirements.
§ 422.2264Beneficiary contact.
§ 422.2265Websites.
§ 422.2266Activities with healthcare providers or in the healthcare setting.
§ 422.2267Required materials and content.
§ 422.2272Licensing of marketing representatives and confirmation of marketing resources.
§ 422.2274Agent, broker, and other third-party requirements.
§ 422.2276Employer group retiree marketing.
§ 422.2400Basis and scope.
§ 422.2401Definitions.
§ 422.2410General requirements.
§ 422.2420Calculation of the medical loss ratio.
§ 422.2430Activities that improve health care quality.
§ 422.2440Credibility adjustment.
§ 422.2450§ 422.2450 [Reserved]
§ 422.2460Reporting requirements.
§ 422.2470Remittance to CMS if the applicable MLR requirement is not met.
§ 422.2480MLR review and non-compliance.
§ 422.2490Release of Part C MLR data.
§ 422.2600Payment appeals.
§ 422.2605Request for reconsideration.
§ 422.2610Hearing official review.
§ 422.2615Review by the Administrator.