Contracting Prohibitions Under the Medicare Advantage (MA)

50 - Contracting Prohibitions Under the Medicare Advantage (MA) Program (Rev. 79, Issued 02-17-06, Effective Date 02-17-06) An MA organization will be subject to a 2-year contracting prohibition when the organization leaves the MA program entirely by non-renewing all of its MA contracts. As long as an MA organization continues to offer at least one MA plan, the prohibition will not apply. If an MA organization that non-renews all of its MA contracts proposes to return to Medicare contracting within the 2-year time period, the organization must provide a written request to CMS asking for an exemption to the prohibition based on special circumstances. The MA organization will automatically be permitted to re-enter the program as of the beginning of the next calendar year if, during the 6-month period beginning on the date the organization notified CMS of the intention to non-renew all of its MA contracts, there was a change in the statute or regulations that had the effect of increasing MA payments in the payment area or areas at issue. The MA organization will also be permitted to re-enter the program if "circumstances. . .warrant special consideration." CMS will evaluate proposed special circumstance requests on a case-by- case basis. However, there are certain special circumstances under which CMS generally will grant an exemption to the 2-year contracting prohibition to allow the MA organization to offer an MA or MA-PD plan as of the beginning of the next calendar year. These circumstances are: 1. The organization is proposing to introduce an MA plan(s) in a geographic area(s) currently served by two or fewer MA plans; 2. The organization is proposing to introduce MA plans in counties other than the counties they had previously withdrawn from when they ended their earlier contract with the Medicare program; 3. The organization proposes to offer a different MA plan type than they had previously offered. For example, an organization that had offered a health maintenance organization may want to reenter the program and offer a preferred provider organization; 4. The organization has undergone a significant change such as a merger or acquisition and could thereby demonstrate that the new entity is essentially a different organization from the one that severed its contracting relationship with CMS. CMS reserves the right to make a determination whether the nature and extent of the organizational change is sufficient to consider the organization as a new entity, and therefore, no longer subjected to the 2-year contracting prohibition. In addition, CMS may grant an exception based on other "special circumstances" than those above, at CMS' discretion.