Medicare Advantage: General References

Medicare Advantage: General References
Medicare Advantage: General References
Medicare Law
The complete compilation of Medicare law contains legal provisions that govern Medicare
coverage (Parts A and B), Medicare Advantage (Part C) and Medicare drug coverage (Part
D).
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Sections 1851 through 1859 of the Social Security Act govern Medicare Advantage
plans.
Medicare Modernization Act (MMA) of 2003
The pertinent provisions about the drug coverage including Part D in Medicare Advantage
plans (MA-PD) are on pages 6 through 66.
Regulations
Regulations are the legal interpretation of the statute by the governmental agency in
charge of administering a statute.
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The Centers for Medicare & Medicaid Services (CMS) administers Medicare, and the
regulations are in Part 422 of Volume 42 the Code of Federal Regulations. (The way
to refer to the regulations in legal citation form is 42 CFR Part 422.)
Guidance
CMS maintains online manuals, which explain the rules and procedures for administering
the Medicare and Medicaid programs. These manuals are the authority language, or
guidance, for providers, contractors, plan sponsors, and any other organization that deals
with these two programs.
There are currently 26 manuals online, 12 of which pertain to Medicare, the others address
Medicaid. Each manual is updated annually, or on an as needed basis.
Medicare Managed Care Manual
The Medicare Managed Care Manual reviews policies and procedures for Medicare
Advantage (MA). It has 19 active chapters. The chapters range in length; some are brief (5
pages), others more extensive (266 pages), depending on the MA topic being explained.
You can find the Managed Care manual online at CMS’s website, or you can access each
chapter here:
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Chapter 1 – General Provisions (20 pages, updated January 7, 2011)
September 2015
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Chapter 2 – Medicare Advantage Enrollment and Disenrollment (266 pages, revised
August 30, 2013)
Chapter 3 – Medicare Marketing Guidelines for Medicare Advantage Plans, Medicare
Advantage Prescription Drug Plans, Prescription Drug Plans, and Section 1876 Cost
Plans (123 pages, revised June 28, 2013)
Chapter 4 – Benefits and Beneficiary Protections (104 pages, updated January 16,
2015)
Chapter 5 – Quality Assessment (64 pages, updated August 8, 2014)
Chapter 6 – Relationships with Providers (23 pages, updated April 27, 2007)
Chapter 7 – Risk Adjustment (75 pages, issued September 19, 2014)
Chapter 8 – Payments to Medicare Advantage Organizations (35 pages, revised
September 19, 2014)
Chapter 9 – Employer/Union Sponsored Group Health Plans (36 pages, updated May
3, 2013)
Chapter 10 – MA Organization Compliance with State Law and Preemption by Federal
Law (6 pages, November 4, 2011)
Chapter 11 – Medicare Advantage Application Procedures and Contract Requirements
(47 pages, April 25, 2007)
Chapter 12 – Effect Change of Ownership (13 pages, updated May 17, 2013)
Chapter 13 – Medicare Managed Care Beneficiary Grievances, Organization
Determinations, and Appeals Applicable to Medicare Advantage Plans, Cost Plans, and
Health Care Prepayment Plans (HCPPs), (collectively referred to as Medicare Health
Plans) (105 pages, updated April 20, 2012)
Chapter 14 – Contract Determinations and Appeals (9 pages, September 2, 2005)
Chapter 15 – Intermediate Sanctions (5 pages, updated September 30, 2005)
Chapter 16a Private-Fee-for-Service Plans (36 pages, May 27, 2011) and Chapter 16b
Special Needs Plans (45 pages, November 28, 2014)
Chapter 17 – Cost Based Payment (see subchapters for total number of pages and
most recent revision date)
Chapter 18 – Health Care Prepayment Plans (see subchapters for total number of
pages and most recent revision date)
Chapter 21- Compliance Program Guidelines (54 pages, updated January 11, 2013)
Final Call Letter to Plans
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This Memorandum was issued to all plans on April 6, 2015 as they prepare to bid for
the 2016 contract year. It helps plan sponsors understand all new guidance and
reviews current policies and procedures. It also contains information on the
standard cost-sharing amounts in the Part D benefit.
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