(a) Basis. This part is based on the indicated provisions of the following:
(1) The following provisions of the Act:
(i) 1106—Disclosure of information in possession of agency.
(ii) 1128J(d)—Reporting and Returning of Overpayments.
(iii) 1851—Eligibility, election, and enrollment.
(iv) 1852—Benefits and beneficiary protections.
(v) 1853—Payments to Medicare Advantage (MA) organizations.
(vi) 1854—Premiums.
(vii) 1855—Organization, licensure, and solvency of MA organizations.
(viii) 1856—Standards.
(ix) 1857—Contract requirements.
(x) 1858—Special rules for MA Regional Plans.
(xi) 1859—Definitions; enrollment restriction for certain MA plans.
(2) 8 U.S.C. 1611—Aliens who are not qualified aliens ineligible for Federal public benefits.
(b) Scope. This part establishes standards and sets forth the requirements, limitations, and procedures for Medicare services furnished, or paid for, by Medicare Advantage organizations through Medicare Advantage plans.
[63 FR 35068, June 26, 1998, as amended at 70 FR 4714, Jan. 28, 2005; 80 FR 7958, Feb. 12, 2015; 81 FR 80556, Nov. 15, 2016]
Notes of Decisions
United Behavioral Health v. Maricopa Integrated Health Sys., 377 P.3d 315 (Ariz. 2016).
“Although neither the enrollees nor the government has a direct financial stake in this dispute, HHS directs and controls how MA Organizations administer benefits, and it therefore has an interest in developing the law on what is “medically necessary.”
Yarick v. PacifiCare of California, 179 Cal. App. 4th 1158 (Cal. Ct. App. 2009).
“437-440; see also Medicare Advantage Program, 42 C.F.R. § 422.1 et seq. (2008).) Respondent provides an MA HMO plan marketed under the name Secure Horizons.”
Main & Assocs., Inc. v. Blue Cross, 90 So. 3d 158 (Ala. 2012).
“The contract between Southern Springs and BCBS specifically requires BCBS to comply with federal regulations: "The Parties acknowledge and agree that [BCBS] is responsible and accountable to CMS for functions and responsibilities described in regulations promulgated by CMS,…”
Dial v. Healthspring of Alabama, Inc., 501 F. Supp. 2d 1348 (S.D. Ala. 2007).
“IV, Subch B, Part 422, Medicare Advantage Program, 42 C.F.R. § 422.1 . Accordingly, plaintiffs’ causes of action based upon defendants’ meeting with the plaintiffs, soliciting their enrollment, and making representations as to the quality and scope of benefits and coverage, and…”
Dignity Health v. Local Initiative Health Care Auth. etc., 44 Cal. App. 5th 144 (Cal. Ct. App. 2020).
“) 14 read “MA organization” (that is, Medicare Advantage8 organization, see 42 C.F.R. § 422.1 (a)(1)(v)) as referring to the “entit[y] responsible for Medicaid payment,” such as a Medicaid managed care organization.”
Prime Healthcare La Palma v. Kaiser Found. Health Plan, No. B296487 (Cal. Ct. App. Aug. 25, 2021).
“Specifically, by regulations the Secretary (through CMS) promulgated under part 422 of title 42 of the Code of Federal Regulations, the Secretary has “establishe[d] standards and set[] forth the requirements, limitations, and procedures for Medicare services furnished, or paid…”
Quishenberry v. UnitedHealthcare, No. B303451 (Cal. Ct. App. Sept. 21, 2021).
“” ( 42 C.F.R. § 422.1 (b).) The regulations include CMS’s approval of the network of MA providers “to ensure that all 12 applicable requirements are met, including access and availability, service area, and quality.”
Destiny Springs Healthcare LLC v. Arizona Physicians IPA Inc., No. 2:23-cv-01694 (D. Ariz. May 2, 2024).
“Defendant alleges 6 that it “assists” a federal officer—CMS—to “fulfill its basic governmental task of 7 administering Medicare benefits under the federal Medicare program” and that, were it not 8 for private MAOs like Defendant, “CMS would have to perform these tasks on its own…”
Annotations are extracted automatically from the opinions in the
Syfert caselaw corpus and ranked by authority, recency, and
treatment. Dots show Syfertize treatment of the citing case itself.