C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 422—MEDICARE ADVANTAGE PROGRAM › Subpart E—Relationships With Providers

42 C.F.R. § 422.205

Provider antidiscrimination rules

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(a) General rule. Consistent with the requirements of this section, the policies and procedures concerning provider selection and credentialing established under § 422.204, and with the requirement under § 422.100(c) that all Medicare-covered services be available to MA plan enrollees, an MA organization may select the practitioners that participate in its plan provider networks. In selecting these practitioners, an MA organization may not discriminate, in terms of participation, reimbursement, or indemnification, against any health care professional who is acting within the scope of his or her license or certification under State law, solely on the basis of the license or certification. If an MA organization declines to include a given provider or group of providers in its network, it must furnish written notice to the effected provider(s) of the reason for the decision.

(b) Construction. The prohibition in paragraph (a)(1) of this section does not preclude any of the following by the MA organization:

(1) Refusal to grant participation to health care professionals in excess of the number necessary to meet the needs of the plan's enrollees (except for MA private-fee-for-service plans, which may not refuse to contract on this basis).

(2) Use of different reimbursement amounts for different specialties or for different practitioners in the same specialty.

(3) Implementation of measures designed to maintain quality and control costs consistent with its responsibilities.

[65 FR 40324, June 29, 2000]
Notes of Decisions
Cited in 1 case, 2014–2014 · leading case: Morrison v. Health Plan of Nev., 2014 NV 55 (Nev. 2014).
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Morrison v. Health Plan of Nev., 2014 NV 55 (Nev. 2014). · cites it 2× “42 C.F.R. § 422.205 (a) (2013). SUPREME COURT OF NEVADA 9 (0) 1947A Act's text does not show that Congress intended the unequal result that Medicare enrollees cannot have legal recourse against a negligent HMO while non-Medicare patients may.”
— 42 C.F.R. § 422.205(a) — 1 case
Morrison v. Health Plan of Nev., 2014 NV 55 (Nev. 2014). “42 C.F.R. § 422.205 (a) (2013). SUPREME COURT OF NEVADA 9 (0) 1947A Act's text does not show that Congress intended the unequal result that Medicare enrollees cannot have legal recourse against a negligent HMO while non-Medicare patients may.”
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