Subpart A - General Provisions

§ 422.1 - Basis and scope.

§ 422.2 - Definitions.

§ 422.3 - xxx

§ 422.4 - Types of MA plans.

§ 422.6 - Cost-sharing in enrollment-related costs.

§ 422.8 - Evaluation and determination procedures.

§ 422.10 - Cost-sharing in enrollment-related costs (M+C user fee).

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.

§ 422.80 - Approval of marketing materials and election forms.

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 - xxx

§ 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 - xxx

§ 422.136 - xxx

§ 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.

§ 422.154 - External review.

§ 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 - xxx

§ 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

§ 422.249 - Terminology.

§ 422.250 - Basis and scope.

§ 422.252 - Terminology.

§ 422.254 - Submission of bids.

§ 422.256 - Review, negotiation, and approval of bids.

§ 422.257 - Encounter data.

§ 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.

§ 422.268 - Source of payment and effect of election of the M+C plan election on payment.

§ 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.

§ 422.302 - Terminology.

§ 422.304 - Monthly payments.

§ 422.306 - Annual MA capitation rates.

§ 422.308 - Adjustments to capitation rates, benchmarks, bids, and payments.

§ 422.309 - Incorrect collections of premiums and cost-sharing.

§ 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).

§ 422.630 - xxx

§ 422.632 - xxx

§ 422.634 - xxx

Requirements Applicable to Certain Integrated Dual Eligible Special Needs Plans

§ 422.629 - General requirements for applicable integrated plans.

§ 422.631 - Integrated organization determinations.

§ 422.633 - Integrated reconsiderations.

Subpart N - Medicare Contract Determinations and Appeals

§ 422.641 - Contract determinations.

§ 422.644 - Notice of contract determination.

§ 422.646 - Effect of contract determination.

§ 422.648 - Reconsideration: Applicability.

§ 422.650 - Request for reconsideration.

§ 422.652 - Opportunity to submit evidence.

§ 422.654 - Reconsidered determination.

§ 422.656 - Notice of reconsidered determination.

§ 422.658 - Effect of reconsidered 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.

§ 422.698 - Effect of revised determination.

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 - XXX

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 - XXX

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.

§ 422.2268 - Standards for MA organization communications and marketing.

§ 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 - XXX

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 - XXX

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.