General Basis for Imposing Intermediate Sanctions on MA

20 - General Basis for Imposing Intermediate Sanctions on MA Organizations (Rev. 73, Issued: 09-30-05, Effective Date: 09-30-05) CMS may impose certain intermediate sanctions on an MA organization for the following violations identified in 42 CFR 422.752(a): • Failing substantially to provide, to an MA enrollee, medically necessary services that the organization is required to provide (under law or under the contract) to an MA enrollee, and that failure adversely affects (or is substantially likely to adversely affect) the enrollee; • Imposing on MA enrollees premiums in excess of the monthly basic and supplemental beneficiary premiums permitted under §1854 of the Social Security Act (the Act) and the Federal Regulations at 42 CFR 422 Subpart F; • Expelling or refusing to re-enroll a beneficiary in violation of the provisions of this part; • Engaging in any practice that could reasonably be expected to have the effect of denying or discouraging enrollment of individuals whose medical condition or history indicates a need for substantial future medical services; • Misrepresenting or falsifying information that it furnishes: i. To CMS; or ii. To an individual or to any other entity. • Failing to comply with the requirements of Federal Regulations at 42 CFR 422.206, which prohibit interference with practitioners' advice to enrollees; • Failing to comply with Federal Regulations at 42 CFR 422.216, which require the organization to enforce the limit on balance billing under a private fee-for-service plan; • Employing or contracting with an individual who is excluded from participation in Medicare under §1128 or §1128A of the Act (or with an entity that employs or contracts with such an individual) for the provision of any of the following: i. Health care; ii. Utilization review; iii. Medical social work; and iv. Administrative services. For the violations described above, CMS may impose one or more of the intermediate sanctions listed in the Federal Regulations at 42 CFR 422.750(a)(2) through (4) - suspension of marketing, enrollment and payment. For these violations, the DHHS/OIG - and not CMS - independently maintains authority to impose CMPs, in addition to, or in place of, sanctions that CMS may impose.