Material Provisions of an MA Contract

100.1 - Material Provisions of an MA Contract (Rev. 79, Issued 02-17-06, Effective Date 02-17-06) 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.