42 CFR 422.752 - Basis for imposing intermediate sanctions and civil money penalties.
(a)All intermediate sanctions. For the violations listed in this paragraph, CMS may impose one or more of the sanctions specified in § 422.750(a) of this subpart on any MA organization with a contract. The MA organization may also be subject to other remedies authorized under law.
(1) Fails substantially to provide medically necessary items and services that are required (under law or under the contract) to be provided to an individual covered under the contract, if the failure has adversely affected (or has the substantial likelihood of adversely affecting) the individual.
(4) Engages in any practice that would reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by this part) by eligible individuals with the organization whose medical condition or history indicates a need for substantial future medical services.
(5) Misrepresents or falsifies information that it furnishes -
(i) To CMS; or
(ii) To an individual or to any other entity.
(6) Fails to comply with the requirements of § 422.206, which prohibits interference with practitioners' advice to enrollees.
(8) Employs or contr acts with an individual or entity who is excluded from participation in Medicare under section 1128 or 1128A of the Act (or with an entity that employs or contracts with such an excluded individual or entity) for the provision of any of the following:
(i) Health care.
(ii) Utilization review.
(iii) Medical social work.
(iv) Administrative services.
(9) Except as provided under § 423.34 of this chapter, enrolls an individual in any plan under this part without the prior consent of the individual or the designee of the individual.
(10) Transfers an individual enrolled under this part from one plan to another without the prior consent of the individual or the designee of the individual or solely for the purpose of earning a commission.
(11) Fails to comply with marketing restrictions described in subpart V or applicable implementing guidance.
(12) Employs or contracts with any individual, agent, provider, supplier or entity who engages in the conduct described in paragraphs (a)(1) through (11) of this section.
(13) Fails to comply with §§ 422.222 and 422.224, that requires the MA organization to ensure providers and suppliers are enrolled in Medicare and not make payment to excluded or revoked individuals or entities.
(b)Suspension of enrollment and marketing. If CMS makes a determination that could lead to a contract termination under 422.510(a), CMS may impose the intermediate sanctions at 422.750(a)(1) and (a)(3).
(c)Civil Money Penalties.
(i) Violations listed at 422.752(a).
(ii) Determinations made under § 422.510(a)(4)(i).
- 42 CFR 422.752 — Basis for Imposing Intermediate Sanctions and Civil Money Penalties.
- 42 CFR 422.506 — Nonrenewal of Contract.
- 42 CFR 422.134 — Reward and Incentive Programs.
- 42 CFR 422.660 — Right to a Hearing, Burden of Proof, Standard of Proof, and Standards of Review.
- 42 CFR 422.216 — Special Rules for MA Private Fee-For-Service Plans.
- 42 CFR 422.2480 — MLR Review and Non-Compliance.
- 42 CFR 422.760 — Determinations Regarding the Amount of Civil Money Penalties and Assessment Imposed by CMS.
- 42 CFR 423.752 — Basis for Imposing Intermediate Sanctions and Civil Money Penalties.
- 42 CFR 422.204 — Provider Selection and Credentialing.