CMS Pub. 100-16, ch. 6, § 50

Consistent with the requirements of this section, the policies and procedures concerning

provider selection and credentialing, and the requirement that all Medicare-covered

services be available to all 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 affected provider(s) on the reason for the

decision.

This prohibition does not preclude any of the following actions by an 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.

(Source: 42 CFR 422.205)