CMS Pub. 100-16, ch. 11, § 100.4

Contracts or other written agreements between MA organizations and providers and

suppliers of health care or health care-related services must contain the following

provisions:

• Contracting providers agree to safeguard beneficiary privacy and confidentiality

and assure accuracy of beneficiary health records;

• Contracts must specify a prompt payment requirement, the terms and conditions

of which are developed and agreed-to by the MA organization and its contracted

providers and suppliers;

• Contracts must hold Medicare members harmless for payment of fees that are the

legal obligation of the MA organization to fulfill. Such provision will apply, but

will not be limited to insolvency of the MA organization, contract breach, and

provider billing;

• Contracts must contain accountability provisions specifying:

o That first tier and downstream entities must comply with Medicare laws,

regulations, and CMS instructions (422.504(i)(4)(v)), and agree to audits

and inspection by CMS and/or its designees and to cooperate, assist, and

provide information as requested, and maintain records a minimum of 10

years;

o That the MA organization oversees and is accountable to CMS for any

functions and responsibilities described in the MA regulations

(422.504(i)(4)(iii)); and

o That MA organizations that choose to delegate functions must adhere to

the delegation requirements - including all provider contract requirements

in these delegation requirements - described in the MA regulations

(422.504(i)(3)(iii); 422.504(i)(4)(i)-(v)).

• Contracts must specify that providers agree to comply with the MA organization's

policies and procedures;

In addition to the provisions mentioned above, MA organizations must include certain

MA-related provisions in the policies and procedures that are distributed to providers and

suppliers that constitute the organizations' health services delivery network. The

following table summarizes these provisions. Access the CFR online.

CONTRACT REQUIREMENTS THROUGH POLICIES, STANDARDS &

MANUALS

Safeguard privacy and maintain records accurately and timely 422.118

Permanent "out of area" members to receive benefits in

continuation area

422.54(b)

Prohibition against discrimination based on health status 422.110(a)

Pay for emergency and urgently needed services 422.100(b)

Pay for renal dialysis for those temporarily out of a service

area

422.100(b)(1)(iv)

Direct access to mammography and influenza vaccinations 422.100(g)(1)

No copay for influenza and pneumococcal vaccines 422.100(g)(2)

Agreements with providers to demonstrate "adequate" access 422.112(a)(1)

Direct access to women's specialists for routine and

preventive services

422.112(a)(3)

Services available 24 hrs/day, 7 days/week 422.112(a)(7)

Adhere to CMS marketing provisions 422.80(a), (b), (c)

Ensure services are provided in a culturally competent

manner

422.112(a)(8)

Maintain procedures to inform members of follow-up care or

provide training in selfcare as necessary

422.112(b)(5)

Document in a prominent place in medial record if individual

has executed advance directive

422.128(b)(1)(ii)(E)

Provide services in a manner consistent with professionally

recognized standards of care

422.504(a)(3)(iii)

Continuation of benefits provisions (may be met in several

ways, including contract provision)

422.504(g)(2)(i);

422.504(g)(2)(ii);

422.504(g)(3)

CONTRACT REQUIREMENTS THROUGH POLICIES, STANDARDS &

MANUALS

Payment and incentive arrangements specified 422.208

Subject to applicable Federal laws 422.504(h)

Disclose to CMS all information necessary to (1) Administer

& evaluate the program (2) Establish and facilitate a process

for current and prospective beneficiaries to exercise choice in

obtaining Medicare services

422.64(a): 422.504(a)(4)

422.504(f)(2)

Must make good faith effort to notify all affected members of

the termination of a provider contract 30 calendar days before

the termination by plan or provider

422.111(e)

Submission of data, medical records and certify completeness

and truthfulness

422.310(d)(3)-(4),

422.310(e), 422.504(d)-

(e), 422.504(i)(3)-(4),

422.504(l)(3)

Comply with medical policy, QI and MM 422.202(b);

422.504(a)(5)

Disclose to CMS quality & performance indicators for plan

benefits re: disenrollment rates for beneficiaries enrolled in

the plan for the previous two years

422.504(f)(2)(iv)(A)

Disclose to CMS quality & performance indicators for the

benefits under the plan regarding enrollee satisfaction

422.504(f)(2)(iv)(B)

Disclose to CMS quality & performance indicators for the

benefits under the plan regarding health outcomes

422.504(f)(2)(iv)(C)

Notify providers in writing for reason for denial, suspension

& termination

422.202(c)(1)

Provide 60 days notice (terminating contract without cause) 422.202(c)(4)

Comply with Federal laws and regulations to include, but not

limited to: Federal criminal law, the False Claims Act (31

U.S.C. 3729 et. Seq.) and the anti-kickback statute (section

1128B(b) of the Act)

422.504(h)(1)

Prohibition of use of excluded practitioners 422.752(a)(8)

Adhere to appeals/grievance procedures 422.562(a)