CMS Pub. 100-16, ch. 11, § 100.1

The contract between the MA organization and CMS will contain the following material

requirements and conditions.

The MA organization shall:

• Accept new enrollments, make enrollments effective, process voluntary

disenrollments, and limit involuntary disenrollments as provided in Chapter 2 of

this manual;

• Not discriminate in regards to beneficiary enrollment;

• Provide the basic benefits and to the extent applicable, supplemental benefits;

• Provide access to services in accordance with the standards set forth at 42 CFR

422.112 (for a coordinated care plan) or 42 CFR 422.114 (for a private fee-for-service plan);

• Provide health care services in a manner consistent with professionally recognized

standards of health care;

• Disclose information to beneficiaries in the manner and the form prescribed by

CMS;

• Operate a quality improvement program in accordance with 42 CFR 422.152;

• Comply with all applicable provider requirements and specific physician

requirements ;

• Comply with all requirements governing coverage determinations, grievances,

and appeals;

• Comply with all reporting requirements including the submission of data;

• Accept payment;

• Develop and submit an annual bid proposal and submit all the required

information on premiums, benefits, and cost-sharing by the due date specified in

the statute, which is the first Monday in June;

• Acknowledge that CMS may not renew or may terminate its MA contract;

• Comply with all the requirements that are specific to a type of MA plan;

• Comply with the confidentiality, privacy, and enrollee record accuracy

requirements;

• Submit to CMS certified financial information demonstrating that the

organization has a fiscally sound operation; and

• Submit to CMS information as CMS may require pertaining to the disclosure of

ownership and control of the MA organization.

An MA organization's noncompliance with material requirements of its MA contract are

grounds for contract termination by CMS.