Disclosure Requirements

110.4.4 - Disclosure Requirements (Rev. 79, Issued 02-17-06, Effective Date 02-17-06) 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.