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Title 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE
& MEDICAID SERVICES,
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
PART 422--MEDICARE ADVANTAGE PROGRAM
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 | 422.1 | Basis and scope. |
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| 422.2 | Definitions. |
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| 422.4 | Types of MA plans. |
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| 422.6 | Cost-sharing in enrollment-related costs. |
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| 422.50 | Eligibility to elect an MA plan. |
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| 422.52 | Eligibility to elect an MA plan for special needs individuals. |
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| 422.54 | Continuation of enrollment for MA local plans. |
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| 422.56 | Enrollment in an MA MSA plan. |
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| 422.57 | Limited enrollment under MA RFB plans. |
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| 422.60 | Election process. |
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| 422.62 | Election of coverage under an MA plan. |
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| 422.64 | Information about the MA program. |
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| 422.66 | Coordination of enrollment and disenrollment through MA organizations. |
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| 422.68 | Effective dates of coverage and change of coverage. |
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| 422.74 | Disenrollment by the MA organization. |
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| 422.80 | Approval of marketing materials and election forms. |
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| 422.100 | General requirements. |
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| 422.101 | Requirements relating to basic benefits. |
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| 422.102 | Supplemental benefits. |
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| 422.103 | Benefits under an MA MSA plan. |
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| 422.104 | Special rules on supplemental benefits for MA MSA plans. |
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| 422.105 | Special rules for self-referral and point of service option. |
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| 422.106 | Coordination of benefits with employer or union group health plans and Medicaid. |
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| 422.108 | Medicare secondary payer (MSP) procedures. |
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| 422.109 | Effect of national coverage determinations (NCDs) and legislative changes in benefits. |
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| 422.110 | Discrimination against beneficiaries prohibited. |
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| 422.111 | Disclosure requirements. |
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| 422.112 | Access to services. |
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| 422.113 | Special rules for ambulance services, emergency and urgently needed services, and maintenance and post-stabilization care services. |
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| 422.114 | Access to services under an MA private fee-for-service plan. |
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| 422.118 | Confidentiality and accuracy of enrollee records. |
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| 422.128 | Information on advance directives. |
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| 422.132 | Protection against liability and loss of benefits. |
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| 422.133 | Return to home skilled nursing facility. |
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| 422.152 | Quality improvement program. |
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| 422.156 | Compliance deemed on the basis of accreditation. |
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| 422.157 | Accreditation organizations. |
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| 422.158 | Procedures for approval of accreditation as a basis for deeming compliance. |
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| 422.200 | Basis and scope. |
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| 422.202 | Participation procedures. |
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| 422.204 | Provider selection and credentialing. |
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| 422.205 | Provider antidiscrimination rules. |
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| 422.206 | Interference with health care professionals' advice to enrollees prohibited. |
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| 422.208 | Physician incentive plans: requirements and limitations. |
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| 422.210 | Assurances to CMS. |
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| 422.212 | Limitations on provider indemnification. |
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| 422.214 | Special rules for services furnished by noncontract providers. |
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| 422.216 | Special rules for MA private fee-for-service plans. |
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| 422.220 | Exclusion of services furnished under a private contract. |
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| 422.250 | Basis and scope. |
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| 422.252 | Terminology. |
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| 422.254 | Submission of bids. |
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| 422.256 | Review, negotiation, and approval of bids. |
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| 422.258 | Calculation of benchmarks. |
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| 422.262 | Beneficiary premiums. |
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| 422.264 | Calculation of savings. |
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| 422.266 | Beneficiary rebates. |
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| 422.270 | Incorrect collections of premiums and cost-sharing. |
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| 422.300 | Basis and scope. |
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| 422.304 | Monthly payments. |
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| 422.306 | Annual MA capitation rates. |
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| 422.308 | Adjustments to capitation rates, benchmarks, bids, and payments. |
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| 422.310 | Risk adjustment data. |
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| 422.312 | Announcement of annual capitation rate, benchmarks, and methodology changes. |
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| 422.314 | Special rules for beneficiaries enrolled in MA MSA plans. |
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| 422.316 | Special rules for payments to Federally qualified health centers. |
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| 422.318 | Special rules for coverage that begins or ends during an inpatient hospital stay. |
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| 422.320 | Special rules for hospice care. |
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| 422.322 | Source of payment and effect of MA plan election on payment. |
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| 422.324 | Payments to MA organizations for graduate medical education costs. |
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| 422.350 | Basis, scope, and definitions. |
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| 422.352 | Basic requirements. |
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| 422.354 | Requirements for affiliated providers. |
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| 422.356 | Determining substantial financial risk and majority financial interest. |
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| 422.370 | Waiver of State licensure. |
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| 422.372 | Basis for waiver of State licensure. |
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| 422.374 | Waiver request and approval process. |
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| 422.376 | Conditions of the waiver. |
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| 422.378 | Relationship to State law. |
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| 422.380 | Solvency standards. |
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| 422.382 | Minimum net worth amount. |
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| 422.384 | Financial plan requirement. |
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| 422.386 | Liquidity. |
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| 422.388 | Deposits. |
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| 422.390 | Guarantees. |
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| 422.400 | State licensure requirement. |
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| 422.402 | Federal preemption of State law. |
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| 422.404 | State premium taxes prohibited. |
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| 422.451 | Moratorium on new local preferred provider organization plans. |
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| 422.455 | Special rules for MA Regional Plans. |
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| 422.458 | Risk sharing with regional MA organizations for 2006 and 2007. |
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| 422.500 | Scope and definitions. |
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| 422.501 | Application requirements. |
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| 422.502 | Evaluation and determination procedures. |
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| 422.503 | General provisions. |
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| 422.504 | Contract provisions. |
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| 422.505 | Effective date and term of contract. |
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| 422.506 | Nonrenewal of contract. |
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| 422.508 | Modification or termination of contract by mutual consent. |
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| 422.510 | Termination of contract by CMS. |
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| 422.512 | Termination of contract by the MA organization. |
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| 422.514 | Minimum enrollment requirements. |
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| 422.516 | Reporting requirements. |
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| 422.520 | Prompt payment by MA organization. |
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| 422.521 | Effective date of new significant regulatory requirements. |
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| 422.524 | Special rules for RFB societies. |
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| 422.527 | Agreements with Federally qualified health centers. |
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| 422.550 | General provisions. |
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| 422.552 | Novation agreement requirements. |
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| 422.553 | Effect of leasing of an MA organization's facilities. |
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| 422.560 | Basis and scope. |
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| 422.561 | Definitions. |
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| 422.562 | General provisions. |
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| 422.564 | Grievance procedures. |
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| 422.566 | Organization determinations. |
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| 422.568 | Standard timeframes and notice requirements for organization determinations. |
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| 422.570 | Expediting certain organization determinations. |
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| 422.572 | Timeframes and notice requirements for expedited organization determinations. |
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| 422.574 | Parties to the organization determination. |
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| 422.576 | Effect of an organization determination. |
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| 422.578 | Right to a reconsideration. |
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| 422.580 | Reconsideration defined. |
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| 422.582 | Request for a standard reconsideration. |
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| 422.584 | Expediting certain reconsiderations. |
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| 422.586 | Opportunity to submit evidence. |
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| 422.590 | Timeframes and responsibility for reconsiderations. |
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| 422.592 | Reconsideration by an independent entity. |
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| 422.594 | Notice of reconsidered determination by the independent entity. |
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| 422.596 | Effect of a reconsidered determination. |
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| 422.600 | Right to a hearing. |
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| 422.602 | Request for an ALJ hearing. |
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| 422.608 | Medicare Appeals Council (MAC) review. |
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| 422.612 | Judicial review. |
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| 422.616 | Reopening and revising determinations and decisions. |
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| 422.618 | How an MA organization must effectuate standard reconsidered determinations or decisions. |
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| 422.619 | How an MA organization must effectuate expedited reconsidered determinations. |
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| 422.620 | How enrollees of MA organizations must be notified of noncovered inpatient hospital care. |
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| 422.622 | Requesting immediate QIO review of noncoverage of inpatient hospital care. |
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| 422.624 | Notifying enrollees of termination of provider services. |
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| 422.626 | Fast-track appeals of service terminations to independent review entities (IREs). |
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| 422.641 | Contract determinations. |
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| 422.644 | Notice of contract determination. |
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| 422.646 | Effect of contract determination. |
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| 422.648 | Reconsideration: Applicability. |
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| 422.650 | Request for reconsideration. |
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| 422.652 | Opportunity to submit evidence. |
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| 422.654 | Reconsidered determination. |
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| 422.656 | Notice of reconsidered determination. |
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| 422.658 | Effect of reconsidered determination. |
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| 422.660 | Right to a hearing. |
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| 422.662 | Request for hearing. |
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| 422.664 | Postponement of effective date of a contract determination when a request for a hearing with respect to a contract determination is filed timely. |
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| 422.666 | Designation of hearing officer. |
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| 422.668 | Disqualification of hearing officer. |
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| 422.670 | Time and place of hearing. |
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| 422.672 | Appointment of representatives. |
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| 422.674 | Authority of representatives. |
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| 422.676 | Conduct of hearing. |
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| 422.678 | Evidence. |
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| 422.680 | Witnesses. |
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| 422.682 | Discovery. |
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| 422.684 | Prehearing. |
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| 422.686 | Record of hearing. |
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| 422.688 | Authority of hearing officer. |
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| 422.690 | Notice and effect of hearing decision. |
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| 422.692 | Review by the Administrator. |
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| 422.694 | Effect of Administrator's decision. |
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| 422.696 | Reopening of contract or reconsidered determination or decision of a hearing officer or the Administrator. |
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| 422.698 | Effect of revised determination. |
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| 422.750 | Kinds of sanctions. |
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| 422.752 | Basis for imposing sanctions. |
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| 422.756 | Procedures for imposing sanctions. |
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| 422.758 | Maximum amount of civil money penalties imposed by CMS. |
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| 422.760 | Other applicable provisions. |
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