CMS Pub. 100-16, ch. 15, § 30

(Rev. 73, Issued: 09-30-05, Effective Date: 09-30-05)

CMS may impose certain intermediate sanctions, including CMPs, on MA organizations

for the same reasons that we can terminate an MA organization's contract under

§422.510(a). In cases involving fraud and abuse DHHS/ OIG, and not CMS, maintains

the authority to impose CMPs.

Federal Regulations at 42 CFR 422.510(a)(1) through (a)(12) permit CMS to terminate

an MA organization's contract or impose intermediate sanctions if the Agency determines:

• The MA organization has failed substantially to carry out the terms of its contract

with CMS;

• The MA organization is carrying out its contract with CMS in a manner that is

inconsistent with the effective and efficient implementation of this part;

• CMS determines that the MA organization no longer meets the requirements of

this part for being a contracting organization;

• The MA organization commits or participates in fraudulent or abusive activities

affecting the Medicare program, including submission of fraudulent data (as

mentioned above, only DHHS/OIG can impose a CMP for this violation);

• The MA organization experiences financial difficulties so severe that its ability to

make necessary health services available is impaired to the point of posing an

imminent and serious risk to the health of its enrollees, or otherwise fails to make

services available to the extent that such a risk to health exists;

• The MA organization substantially fails to comply with the requirements of the

Federal Regulations at 42 CFR 422 Subpart M of this part relating to grievances

and appeals;

• The MA organization fails to provide CMS with valid data as required under

Federal Regulations at 42 CFR 422.310;

• The MA organization fails to implement an acceptable quality improvement

program as required under Federal Regulations at 42 CFR 422 Subpart D of this

part;

• The MA organization substantially fails to comply with the prompt payment

requirements in the Federal Regulations at 42 CFR 422.520;

• The MA organization substantially fails to comply with the service access

requirements in the Federal Regulations at 42 CFR 422.112 or the Federal

Regulations at 42 CFR 422.114;

• The MA organization fails to comply with the requirements of the Federal

Regulations at 42 CFR 422.208 regarding physician incentive plans; or

• The MA organization substantially fails to comply with the marketing

requirements in the Federal Regulations at 42 CFR 422.80.

CMS may impose CMPs for the reasons outlined at §422.510(a), other than fraud or

abuse, if the deficiency on which the sanction determination is based has directly

adversely affected (or has the substantial likelihood of adversely affecting) one or

more MA enrollees. In such cases the amount of the CMS-imposed CMP is $25,000

for each determination. For each week that a deficiency remains uncorrected after the

week in which the MA organization receives CMS's notice of the determination to

impose a CMP, CMS may further impose CMPs in the amount of $10,000.