Changes in MCM Chapter 11, Medicare Advantage Application Procedures and Contract Requirements

This revision makes the following changes:
The Title – is revised to read as Chapter 11, Medicare Advantage Application Procedures
and Contract Requirements;
Section 20.1. – Added section on “Application Procedures and Conditions for Entering
an MA Contract;”
Section 20.2 – Added section on “Evaluation and Determination of Applications,”
Section 20.3 – Added information related to the fraud, waste, and abuse provisions that
MA-PDs must follow;
Section 60 –Added information on other operational guidance affecting the contract
renewal process;
Section 70.1 – Updated the contract renewal section to reflect new timelines;
Section 70.2 – Specified the kinds of records subject to financial audits; updated §70.2.5
to reflect new quality improvement provisions;
Section 100.2 – Added section on payments to Federally Qualified Health Centers;
Section 110.4.3 – Updated the maintenance and access to MA-related records section by
including the 10 year/current contract period and 10 prior contract period language;
Section 120 – Specified that MA organizations must comply with other laws and
regulations designed to prevent fraud, waste, and abuse; specified that MA-PDs must
follow the Part 423 requirements governing the Medicare prescription drug benefit for a
comprehensive fraud, waste, and abuse program;
Section 150 – Removed employer/union plan sections. These are being developed into a
stand alone chapter;
Appendix A – Replaced the previous risk adjustment data certification with a
“Certification of Monthly Enrollment and Payment Data Relating to CMS Payment to an
MA Organization;” and
General – Revised nomenclature and references throughout the Chapter to reflect new
bidding and payment processes; quality improvement changes; Part D fraud, waste, and
abuse requirements; and the reorganization/revision of several sections of the previous
Medicare + Choice regulations.

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