Termination of contract by CMS.

(1) Termination of contract by CMS.

Source

42 CFR § 422.510


Scoping language

Termination by CMS. CMS may at any time terminate a contract if CMS determines that the MA organization meets any of the following:
(1) Has failed substantially to carry out the contract.
(2) Is carrying out the contract in a manner that is inconsistent with the efficient and effective administration of this part.
(3) No longer substantially meets the applicable conditions of this part.
(4) CMS may make a determination under paragraph (a)(1), (2), or (3) of this section if the MA organization has had one or more of the following occur:
(i) Based on creditable evidence, has committed or participated in false, fraudulent or abusive activities affecting the Medicare, Medicaid or other State or Federal health care programs, including submission of false or fraudulent data.
(ii) Substantially failed to comply with the requirements in subpart M of this part relating to grievances and appeals.
(iii) Failed to provide CMS with valid data as required under § 422.310.
(iv) Failed to implement an acceptable quality assessment and performance improvement program as required under subpart D of this part.
(v) Substantially failed to comply with the prompt payment requirements in § 422.520.
(vi) Substantially failed to comply with the service access requirements in § 422.112 or § 422.114.
(vii) Failed to comply with the requirements of § 422.208 regarding physician incentive plans.
(viii) Substantially fails to comply with the requirements in subpart V of this part.
(ix) Failed to comply with the regulatory requirements contained in this part or part 423 of this chapter or both.
(x) Failed to meet CMS performance requirements in carrying out the regulatory requirements contained in this part or part 423 of this chapter or both.
(xi) Achieves a Part C summary plan rating of less than 3 stars for 3 consecutive contract years. Plan ratings issued by CMS before September 1, 2012 are not included in the calculation of the 3-year period.
(xii) Has failed to report MLR data in a timely and accurate manner in accordance with § 422.2460 or that any MLR data required by this subpart is found to be materially incorrect or fraudulent.
(xiii) Fails to meet the preclusion list requirements in accordance with § 422.222 and 422.224.
(xiv) The MA organization has committed any of the acts in § 422.752(a) that support the imposition of intermediate sanctions or civil money penalties under subpart O of this part.
(xv) Following the issuance of a notice to the MA organization no later than August 1, CMS must terminate, effective December 31 of the same year, an individual MA plan if that plan does not have a sufficient number of enrollees to establish that it is a viable independent plan option.

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