CMS Pub. 100-16, ch. 11, § 110.4.4

The MA organization agrees to disclose the following to CMS:

• Certified financial information that must include the following:

o Such information as CMS may require demonstrating that the organization

has a fiscally sound operation; and

o Such information as CMS may require pertaining to the disclosure of

ownership and control of the MA organization.

• All information that is necessary for CMS to administer and evaluate the program

and to simultaneously establish and facilitate a process for current and prospective

beneficiaries to exercise choice in obtaining Medicare services. This information

includes, but is not limited to:

o The benefits covered under an MA plan;

o The MA monthly basic beneficiary premium and MA monthly

supplemental beneficiary premium, if any, for the plan or in the case of an

MSA plan, the MA monthly MSA premium;

o The service area and continuation area, if any, of each plan and the

enrollment capacity of each plan; and

o The plan quality and performance indicators for the benefits under the

plan including:

ƒ Disenrollment rates for Medicare enrollees electing to receive

benefits through the plan for the previous 2 years;

ƒ Information on Medicare enrollee satisfaction;

ƒ Information on health outcomes;

ƒ The recent record regarding compliance of the plan with

requirements of this part, as determined by CMS; and

ƒ Other information determined by CMS to be necessary to assist

beneficiaries in making an informed choice among MA plans and

traditional Medicare;

o Information about beneficiary appeals and their disposition;

o Information regarding all formal actions, reviews, findings, or other

similar actions by States, other regulatory bodies, or any other certifying

or accrediting organization; and

o Any other information deemed necessary by CMS for the administration

or evaluation of the Medicare program.

• MA organizations must disclose to existing enrollees and to each new enrollee

electing an MA plan it offers in clear, accurate, and standardized form; and at the

time of enrollment and at least annually thereafter, information relating to the MA

organization's MA plans, including:

o The MA plan's service area and any enrollment continuation area;

o The benefits offered under the plan, including applicable conditions and

limitations, premiums, cost sharing (such as copayments, deductibles, and

coinsurance), and any other conditions associated with receipt or use of

benefits; and for purposes of comparison;

o The benefits offered under original Medicare;

o For an MA Medical Savings Account (MSA) plan, the benefits under

other types of MA plans; and

o The availability of the Medicare hospice option and any approved

hospices in the service area, including those the MA organization owns,

controls, or has a financial interest in.

• The number, mix, and distribution of providers from whom enrollees may obtain

services; any out-of network coverage; any point-of-service option, including the

supplemental premium for that option; and how the MA organization meets MA

access to service requirements;

• Out-of-area coverage provided by the plan;

• Coverage of emergency services, including:

o Explanation of what constitutes an emergency, referencing the definitions

of emergency services and emergency medical condition at 42 CFR

422.113;

o The appropriate use of emergency services, stating that prior authorization

cannot be required;

o The process and procedures for obtaining emergency services, including

use of the 911 telephone system or its local equivalent;

o The locations where emergency care can be obtained and other locations

at which contracting physicians and hospitals provide emergency services

and post-stabilization care included in the MA plan;

• Any mandatory or optional supplemental benefits and the premium for those

benefits;

• Prior authorization rules and other review requirements that must be met in order

to ensure payment for the services. The MA organization must instruct enrollees

that, in cases where noncontracting providers submit a bill directly to the enrollee,

the enrollee should not pay the bill, but submit it to the MA organization for

processing and determination of enrollee liability, if any;

• All grievance and appeals rights and procedures;

• A description of the MA organization's quality assurance program; and

• Enrollees' disenrollment rights and responsibilities.

Upon request of an individual eligible to elect an MA plan, an MA organization must

provide to the individual the following information:

• Benefits under original Medicare, including covered services, beneficiary cost

sharing, such as deductibles, coinsurance, copayment amounts and any

beneficiary liability for balance billing;

• Information and instructions on how to exercise election options under this

subpart;

• A general description of procedural rights (including grievance and appeals

procedures) under original Medicare and the MA program and the right to be

protected against discrimination based on factors related to health status;

• The fact that an MA organization may terminate or refuse to renew its contract, or

reduce the service area included in its contract, and the effect that any of those

actions may have on individuals enrolled in that organization's MA plan;

• Benefits, including covered services beyond those provided under original

Medicare, any beneficiary cost sharing, and any maximum limitations on out-of-pocket expenses, the extent to which an enrollee may obtain benefits through out-of-network health care providers, the types of providers that participate in the

plan's network and the extent to which an enrollee may select among those

providers, and the coverage of emergency and urgently needed services. In the

case of an MA MSA plan, the amount of the annual MSA deposit and the

differences in cost-sharing, enrollee premiums, and balance billing, as compared

to MA plans. In the case of a MA private fee-for-service plan, differences in cost

sharing, enrollee premiums, and balance billing, as compared to MA plans;

• The MA monthly basic beneficiary premium and the MA monthly supplemental

beneficiary premium (if any);

• The plan's service area;

• Quality and performance indicators for benefits under a plan to the extent they are

available as follows (and how they compare with indicators under original

Medicare):

o Disenrollment rates for Medicare enrollees for the 2 previous years,

excluding disenrollment due to death or moving outside the plan's service

area, calculated according to CMS guidelines;

o Medicare enrollee satisfaction;

o Health outcomes;

o Plan-level appeal data;

o The recent record of plan compliance with the requirements of this part, as

determined by the Secretary; and

o Other performance indicators.

• Whether the plan offers mandatory supplemental benefits or offers optional

supplemental benefits and the premiums and other terms and conditions for those

benefits;

• The procedures the organization uses to control utilization of services and

expenditures;

• The number of disputes, and the disposition in the aggregate, in a manner and

form described by the Secretary. Such disputes shall be categorized as:

o Grievances according to Subpart M of 42 CFR 422 and Chapter 13 of this

manual, when published;

o Appeals according to Subpart M of 42 CFR 422 and Chapter 13 of this

manual, when published. A summary description of the method of

compensation for physicians;

• Financial condition of the MA organization, including the most recently audited

information regarding, at least, a description of the financial condition of the MA

organization offering the plan. Other MA organizational financial information that

must be disclosed:

o The cost of its operations;

o The patterns of utilization of its services;

o The availability, accessibility, and acceptability of its services;

o To the extent practical, developments in the health status of its enrollees;

o Information demonstrating that the MA organization has a fiscally sound

operation; and

o Other matters that CMS may require.