2001 CFR Title 47, Volume 4

Title 42--Public Health CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES PART 422--MEDICARE+CHOICE PROGRAM
	422.1	Basis and scope.
	422.2	Definitions.
	422.4	Types of M+C plans.
	422.6	Application requirements.
	422.8	Evaluation and determination procedures.
	422.10	Cost-sharing in enrollment-related costs (M+C user fee).
	422.50	Eligibility to elect an M+C plan.
	422.54	Continuation of enrollment.
	422.56	Limitations on enrollment in an M+C MSA plan.
	422.57	Limited enrollment under M+C RFB plans.
	422.60	Election process.
	422.62	Election of coverage under an M+C plan.
	422.64	Information about the M+C program.
	422.66	Coordination of enrollment and disenrollment through M+C organizations.
	422.68	Effective dates of coverage and change of coverage.
	422.74	Disenrollment by the M+C organization.
	422.80	Approval of marketing materials and election forms.
	422.100	General requirements.
	422.101	Requirements relating to basic benefits.
	422.102	Supplemental benefits.
	422.103	Benefits under an M+C MSA plan.
	422.104	Special rules on supplemental benefits for M+C MSA plans.
	422.105	Special rules for point of service option.
	422.106	Coordination of benefits with employer group health plans and Medicaid.
	422.108	Medicare secondary payer (MSP) procedures.
	422.109	Effect of national coverage determinations (NCDs).
	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 M+C private fee-for-service plan.
	422.118	Confidentiality and accuracy of enrollee records.
	422.128	Information on advance directives.
	422.132	Protection against liability and loss of benefits.
	422.152	Quality assessment and performance improvement program.
	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.
	422.200	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	Disclosure of physician incentive plans
	422.212	Limitations on provider indemnification.
	422.214	Special rules for services furnished by noncontract providers.
	422.216	Special rules for M+C private fee-for-service plans.
	422.220	Exclusion of services furnished under a private contract.
	422.249	Terminology.
	422.250	General provisions.
	422.252	Annual capitation rates.
	422.254	Calculation and adjustment factors.
	422.256	Adjustments to capitation rates and aggregate payments.
	422.257	Encounter data.
	422.258	Announcement of annual capitation rates and methodology changes.
	422.262	Special rules for beneficiaries enrolled in M+C MSA plans.
	422.264	Special rules for coverage that begins or ends during an inpatient hospital stay.
	422.266	Special rules for hospice care.
	422.268	Source of payment and effect of election of the M+C plan election on payment.
	422.270	Payments to M+C organizations for graduate medical education costs.
	422.300	Basis and scope.
	422.302	Terminology.
	422.304	Rules governing premiums and cost-sharing.
	422.306	Submission of proposed premiums and related information.
	422.308	Limits on premiums and cost sharing amounts.
	422.309	Incorrect collections of premiums and cost-sharing.
	422.310	Adjusted community rate (ACR) approval process.
	422.312	Requirement for additional benefits.
	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.
	422.400	State licensure requirement.
	422.402	Federal preemption of State law.
	422.404	State premium taxes prohibited.
	422.500	Definitions.
	422.501	General provisions.
	422.502	Contract provisions.
	422.504	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 M+C organization.
	422.514	Minimum enrollment requirements.
	422.516	Reporting requirements.
	422.520	Prompt payment by M+C organization.
	422.524	Special rules for RFB societies.
	422.550	General provisions.
	422.552	Novation agreement requirements.
	422.553	Effect of leasing of an M+C organization's facilities.
	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	Departmental Appeals Board (the Board) review.
	422.612	Judicial review.
	422.616	Reopening and revising determinations and decisions.
	422.618	How an M+C organization must effectuate standard reconsidered determinations or decisions.
	422.619	How an M+C organization must effectuate expedited reconsidered determinations.
	422.620	How enrollees of M+C organizations must be notified of noncoverage of inpatient hospital care.
	422.622	Requesting immediate PRO review of noncoverage of inpatient hospital care.
	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.
	422.662	Request for hearing.
	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.
	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	Discovery.
	422.684	Prehearing.
	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 contract or reconsidered determination or decision of a hearing officer or the Administrator.
	422.698	Effect of revised determination.
	422.750	Kinds of sanctions.
	422.752	Basis for imposing sanctions.
	422.756	Procedures for imposing sanctions.
	422.758	Maximum amount of civil money penalties imposed by CMS.
	422.760	Other applicable provisions.