42 C.F.R. § 422.300
Basis and scope
This subpart is based on sections 1106, 1128J(d), 1852, 1853, 1854, and 1858 of the Act. It sets forth the requirements for making payments to MA organizations offering local and regional MA policies, including calculation of MA capitation rates and benchmarks, conditions under which payment is based on plan bids, adjustments to capitation rates (including risk adjustment), collection of risk adjustment data, conditions for use and disclosure of risk adjustment data, collection of improper payments and other payment rules. Section 422.458 specifies the requirements for risk sharing payments to MA regional organizations.
Notes of Decisions
Cited in 3
cases (1 in the last 5 years), 2009–2021 · leading case: United States Ex Rel. Wilkins v. United Health Grp., Inc., 659 F.3d 295 (3rd Cir. 2011).
United States Ex Rel. Wilkins v. United Health Grp., Inc., 659 F.3d 295 (3rd Cir. 2011). “See 42 C.F.R. §§ 422.300 et seq. CMS makes advance monthly payments to participants calculated on the number of enrollees, adjusted to reflect risk and variations in rates within the plan's service area.”
Yarick v. PacifiCare of California, 179 Cal. App. 4th 1158 (Cal. Ct. App. 2009). “(See 42 C.F.R. § 422.300 et seq. (2008).) Similarly, as relevant in this case, respondent contracts with a physicians group and two hospitals for provision of direct services to enrollees, again based, primarily, on a negotiated monthly fee for each enrollee regardless of…”
United States of Am. ex rel Tali Arik, M.D. v. DVH Hosp. All., LLC, Inc. (D. Nev. 2021). “21 31 42 C.F.R. §§ 422.300 , 422.304(a). 32 Id.”
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