CFR /  Title 42  /  Part 422: Medicare Advantage Program

Section No.	Description
Section 422.1	Definitions
Section 422.2	Types of MA plans
Section 422.4	Cost-sharing in enrollment-related costs
Section 422.6	Eligibility to elect an MA plan
Section 422.50	Eligibility to elect an MA plan for special needs individuals
Section 422.52	Eligibility to elect an MA plan for senior housing facility residents
Section 422.53	Continuation of enrollment for MA local plans
Section 422.54	Enrollment in an MA MSA plan
Section 422.56	Limited enrollment under MA RFB plans
Section 422.57	Election process
Section 422.60	Election of coverage under an MA plan
Section 422.62	Information about the MA program
Section 422.64	Coordination of enrollment and disenrollment through MA organizations
Section 422.66	Effective dates of coverage and change of coverage
Section 422.68	Disenrollment by the MA organization
Section 422.74	General requirements
Section 422.100	Requirements relating to basic benefits
Section 422.101	Supplemental benefits
Section 422.102	Benefits under an MA MSA plan
Section 422.103	Special rules on supplemental benefits for MA MSA plans
Section 422.104	Special rules for self-referral and point of service option
Section 422.105	Coordination of benefits with employer or union group health plans and Medicaid
Section 422.106	Special needs plans and dual-eligibles: Contract with State Medicaid Agency
Section 422.107	Medicare secondary payer (MSP) procedures
Section 422.108	Effect of national coverage determinations (NCDs) and legislative changes in benefits
Section 422.109	Discrimination against beneficiaries prohibited
Section 422.110	Disclosure requirements
Section 422.111	Access to services
Section 422.112	Special rules for ambulance services, emergency and urgently needed services, and maintenance and post-stabilization
Section 422.113	Access to services under an MA private fee-for-service plan
Section 422.114	Confidentiality and accuracy of enrollee records
Section 422.118	Information on advance directives
Section 422.128	Protection against liability and loss of benefits
Section 422.132	Return to home skilled nursing facility
Section 422.133	Reward and incentive programs
Section 422.134	Quality improvement program
Section 422.152	Use of quality improvement organization review information
Section 422.153	Compliance deemed on the basis of accreditation
Section 422.156	Accreditation organizations
Section 422.157	Procedures for approval of accreditation as a basis for deeming compliance
Section 422.158	Basis and scope
Section 422.200	Participation procedures
Section 422.202	Provider selection and credentialing
Section 422.204	Provider antidiscrimination rules
Section 422.205	Interference with health care professionals' advice to enrollees prohibited
Section 422.206	Physician incentive plans: requirements and limitations
Section 422.208	Assurances to CMS
Section 422.210	Limitations on provider indemnification
Section 422.212	Special rules for services furnished by noncontract providers
Section 422.214	Special rules for MA private fee-for-service plans
Section 422.216	Exclusion of services furnished under a private contract
Section 422.220	Basis and scope
Section 422.250	Terminology
Section 422.252	Submission of bids
Section 422.254	Review, negotiation, and approval of bids
Section 422.256	Calculation of benchmarks
Section 422.258	Appeals of quality bonus payment determinations
Section 422.260	Beneficiary premiums
Section 422.262	Calculation of savings
Section 422.264	Beneficiary rebates
Section 422.266	Incorrect collections of premiums and cost-sharing
Section 422.270	Basis and scope
Section 422.300	Monthly payments
Section 422.304	Annual MA capitation rates
Section 422.306	Adjustments to capitation rates, benchmarks, bids, and payments
Section 422.308	Risk adjustment data
Section 422.310	RADV audit dispute and appeal processes
Section 422.311	Announcement of annual capitation rate, benchmarks, and methodology changes
Section 422.312	Special rules for beneficiaries enrolled in MA MSA plans
Section 422.314	Special rules for payments to Federally qualified health centers
Section 422.316	Special rules for coverage that begins or ends during an inpatient hospital stay
Section 422.318	Special rules for hospice care
Section 422.320	Source of payment and effect of MA plan election on payment
Section 422.322	Payments to MA organizations for graduate medical education costs
Section 422.324	Reporting and returning of overpayments
Section 422.326	CMS-identified overpayments associated with payment data submitted by MA organizations
Section 422.330	Basis, scope, and definitions
Section 422.350	Basic requirements
Section 422.352	Requirements for affiliated providers
Section 422.354	Determining substantial financial risk and majority financial interest
Section 422.356	Waiver of State licensure
Section 422.370	Basis for waiver of State licensure
Section 422.372	Waiver request and approval process
Section 422.374	Conditions of the waiver
Section 422.376	Relationship to State law
Section 422.378	Solvency standards
Section 422.380	Minimum net worth amount
Section 422.382	Financial plan requirement
Section 422.384	Liquidity
Section 422.386	Deposits
Section 422.388	Guarantees
Section 422.390	State licensure requirement
Section 422.400	Federal preemption of State law
Section 422.402	State premium taxes prohibited
Section 422.404	Moratorium on new local preferred provider organization plans
Section 422.451	Special rules for MA Regional Plans
Section 422.455	Risk sharing with regional MA organizations for 2006 and 2007
Section 422.458	Scope and definitions
Section 422.500	Application requirements
Section 422.501	Evaluation and determination procedures
Section 422.502	General provisions
Section 422.503	General provisions
Section 422.503	Contract provisions
Section 422.504	Effective date and term of contract
Section 422.505	Nonrenewal of contract
Section 422.506	Modification or termination of contract by mutual consent
Section 422.508	Termination of contract by CMS
Section 422.510	Termination of contract by the MA organization
Section 422.512	Minimum enrollment requirements
Section 422.514	Validation of Part C reporting requirements
Section 422.516	Prompt payment by MA organization
Section 422.520	Effective date of new significant regulatory requirements
Section 422.521	Special rules for RFB societies
Section 422.524	Agreements with Federally qualified health centers
Section 422.527	General provisions
Section 422.550	Novation agreement requirements
Section 422.552	Effect of leasing of an MA organization's facilities
Section 422.553	Basis and scope
Section 422.560	Definitions
Section 422.561	General provisions
Section 422.562	Grievance procedures
Section 422.564	Organization determinations
Section 422.566	Standard timeframes and notice requirements for organization determinations
Section 422.568	Expediting certain organization determinations
Section 422.570	Timeframes and notice requirements for expedited organization determinations
Section 422.572	Parties to the organization determination
Section 422.574	Effect of an organization determination
Section 422.576	Right to a reconsideration
Section 422.578	Reconsideration defined
Section 422.580	Request for a standard reconsideration
Section 422.582	Expediting certain reconsiderations
Section 422.584	Opportunity to submit evidence
Section 422.586	Timeframes and responsibility for reconsiderations
Section 422.590	Reconsideration by an independent entity
Section 422.592	Notice of reconsidered determination by the independent entity
Section 422.594	Effect of a reconsidered determination
Section 422.596	Right to a hearing
Section 422.600	Request for an ALJ hearing
Section 422.602	Medicare Appeals Council (MAC) review
Section 422.608	Judicial review
Section 422.612	Reopening and revising determinations and decisions
Section 422.616	How an MA organization must effectuate standard reconsidered determinations or decisions
Section 422.618	How an MA organization must effectuate expedited reconsidered determinations
Section 422.619	Notifying enrollees of hospital discharge appeal rights
Section 422.620	Requesting immediate QIO review of the decision to discharge from the inpatient hospital
Section 422.622	Notifying enrollees of termination of provider services
Section 422.624	Fast-track appeals of service terminations to independent review entities (IREs)
Section 422.626	Contract determinations
Section 422.641	Notice of contract determination
Section 422.644	Effect of contract determination
Section 422.646	Right to a hearing, burden of proof, standard of proof, and standards of review
Section 422.660	Request for hearing
Section 422.662	Postponement of effective date of a contract determination when a request for a hearing is filed timely
Section 422.664	Designation of hearing officer
Section 422.666	Disqualification of hearing officer
Section 422.668	Time and place of hearing
Section 422.670	Appointment of representatives
Section 422.672	Authority of representatives
Section 422.674	Conduct of hearing
Section 422.676	Evidence
Section 422.678	Witnesses
Section 422.680	Witness lists and documents
Section 422.682	Prehearing and summary judgment
Section 422.684	Record of hearing
Section 422.686	Authority of hearing officer
Section 422.688	Notice and effect of hearing decision
Section 422.690	Review by the Administrator
Section 422.692	Effect of Administrator's decision
Section 422.694	Reopening of a contract determination or decision of a hearing officer or the Administrator
Section 422.696	Types of intermediate sanctions and civil money penalties
Section 422.750	Basis for imposing intermediate sanctions and civil money penalties
Section 422.752	Procedures for imposing intermediate sanctions and civil money penalties
Section 422.756	Collection of civil money penalties imposed by CMS
Section 422.758	Determinations regarding the amount of civil money penalties and assessment imposed by CMS
Section 422.760	Settlement of penalties
Section 422.762	Other applicable provisions
Section 422.764	Basis and scope
Section 422.1000	Definitions
Section 422.1002	Scope and applicability
Section 422.1004	Appeal rights
Section 422.1006	Appointment of representatives
Section 422.1008	Authority of representatives
Section 422.1010	Fees for services of representatives
Section 422.1012	Charge for transcripts
Section 422.1014	Filing of briefs with the Administrative Law Judge or Departmental Appeals Board, and opportunity for rebuttal
Section 422.1016	Notice and effect of initial determinations
Section 422.1018	Request for hearing
Section 422.1020	Parties to the hearing
Section 422.1022	Designation of hearing official
Section 422.1024	Disqualification of Administrative Law Judge
Section 422.1026	Prehearing conference
Section 422.1028	Notice of prehearing conference
Section 422.1030	Conduct of prehearing conference
Section 422.1032	Record, order, and effect of prehearing conference
Section 422.1034	Time and place of hearing
Section 422.1036	Change in time and place of hearing
Section 422.1038	Joint hearings
Section 422.1040	Hearing on new issues
Section 422.1042	Subpoenas
Section 422.1044	Conduct of hearing
Section 422.1046	Evidence
Section 422.1048	Witnesses
Section 422.1050	Oral and written summation
Section 422.1052	Record of hearing
Section 422.1054	Waiver of right to appear and present evidence
Section 422.1056	Dismissal of request for hearing
Section 422.1058	Dismissal for abandonment
Section 422.1060	Dismissal for cause
Section 422.1062	Notice and effect of dismissal and right to request review
Section 422.1064	Vacating a dismissal of request for hearing
Section 422.1066	Administrative Law Judge's decision
Section 422.1068	Removal of hearing to Departmental Appeals Board
Section 422.1070	Remand by the Administrative Law Judge
Section 422.1072	Right to request Departmental Appeals Board review of Administrative Law Judge's decision or dismissal
Section 422.1074	Request for Departmental Appeals Board review
Section 422.1076	Departmental Appeals Board action on request for review
Section 422.1078	Procedures before the Departmental Appeals Board on review
Section 422.1080	Evidence admissible on review
Section 422.1082	Decision or remand by the Departmental Appeals Board
Section 422.1084	Effect of Departmental Appeals Board Decision
Section 422.1086	Extension of time for seeking judicial review
Section 422.1088	Basis, timing, and authority for reopening an Administrative Law Judge or Board decision
Section 422.1090	Revision of reopened decision
Section 422.1092	Notice and effect of revised decision
Section 422.1094	Definitions concerning marketing materials
Section 422.2260	Review and distribution of marketing materials
Section 422.2262	Guidelines for CMS review
Section 422.2264	Standards for MA organization marketing
Section 422.2268	Licensing of marketing representatives and confirmation of marketing resources
Section 422.2272	Broker and agent requirements
Section 422.2274	Employer group retiree marketing
Section 422.2276	Basis and scope
Section 422.2400	Definitions
Section 422.2401	General requirements
Section 422.2410	Calculation of the medical loss ratio
Section 422.2420	Activities that improve health care quality
Section 422.2430	Credibility adjustment
Section 422.2440	Reporting requirements
Section 422.2460	Remittance to CMS if the applicable MLR requirement is not met
Section 422.2470	MLR review and non-compliance
Section 422.2480	Payment appeals
Section 422.2600	Request for reconsideration
Section 422.2605	Hearing official review
Section 422.2610	Review by the Administrator
Section 422.2615	Basis and scope