Part 422 — Medicare Advantage Program
Subpart A — General Provisions
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
Subpart J — Special Rules for MA Regional Plans
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
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).
- § 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.
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 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 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.
- § 422.2460— 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.