CMS Pub. 100-16, ch. 11, § 110.3

MA organizations, provider groups, individual providers and CMS have a common

interest in preventing delegated provider group financial difficulties that may negatively

impact the well being of Medicare beneficiaries. Similarly, these parties share an interest

in mitigating the impact that provider group failures might have upon Medicare

beneficiaries enrolled in an MA product.

The following is a list of MA regulations that are relevant to MA organizations that have

relationships with delegated entities. These requirements hold MA organizations

responsible for providing care to Medicare beneficiaries, and for protecting Medicare

beneficiaries in instances where delegated entities experience operational difficulties that

may result in failure of the delegated entity to perform delegated functions.

• 422.100(a) - an MA organization offering an MA plan must provide enrollees in

that plan with coverage of the (plan benefit package) by furnishing the services

directly or through arrangements, or by paying for the benefits;

• 422.112(b) - The MA organization must ensure continuity of care and integration

of services;

• 422.504(g)(1) - Each MA organization must adopt and maintain arrangements

satisfactory to CMS to protect its enrollees from incurring liability for payment of

any fees that are the legal obligation of the MA organization;

• 422.504(i)(1) - Notwithstanding any relationship(s) that the MA organization may

have with related entities, contractors, or subcontractors, the MA organization

maintains ultimate responsibility for adhering to and otherwise fully complying

with all terms and conditions of its contract with CMS;

• 422.502(i)(4)(i)-(v) - If any of the MA organization's activities or responsibilities

under its contract with CMS are delegated to other parties, written arrangements

must specify that the performance of the parties is monitored by the MA

organization on an ongoing basis, and either provide for revocation of the

delegated activities or specify other remedies where CMS or the MA organization

determines such parties have not performed satisfactorily.

The policies and procedures described in §110.4 are recommended but not required for

MA Organizations to ensure the operational integrity of delegated entities, and to protect

beneficiaries in the event of a delegated provider group(s) insolvency and/or termination.

This additional guidance may prove helpful to MA organizations in their attempt to meet

the aforementioned MA regulatory requirements.