The MA organization agrees to comply with all the applicable requirements and conditions set forth in this part and in general instructions. The MA organization agrees:
- To provide:
- The basic benefits and, to the extent applicable, supplemental benefits.
- Access to benefits as required.
- In a manner consistent with professionally recognized standards of health care, all benefits covered by Medicare.
- To disclose information to beneficiaries in the manner and the form prescribed by CMS.
- To operate a quality assurance and performance improvement program and have an agreement for external quality review.
- To certify the accuracy, completeness and truthfulness of relevant data that CMS requests:
- The CEO, CFO or an individual delegated the authority to sign on behalf of one of these officers, and who reports directly to such officer, must certify that each enrollee for whom the organization is requesting payment is validly enrolled in an MA plan offered by the organization and the information relied upon by CMS in determining payment (based on best knowledge, information and belief) is accurate, complete and truthful.
- The CEO, CFO or an individual delegated with the authority to sign on behalf of one of these officers, and who reports directly to such officer, must certify (based on best knowledge, information and belief) that the data it submits is accurate, complete and truthful.
- If such data is generated by a related entity, contractor or subcontractor of an MA organization, such entity, contractor or subcontractor must similarly certify (based on best knowledge, information and belief) the accuracy, completeness and truthfulness of the data.
- To submit to CMS all information necessary for CMS to administer and evaluate the program and to simultaneously establish and facilitate a process for current and prospective beneficiaries to exercise choice in obtaining Medicare services. This information includes, but is not limited, to:
- The benefits covered under an MA plan.
- The MA monthly basic beneficiary premium and MA monthly supplemental beneficiary premium, if any, for the plan.
- The service area and continuation area, if any, of each plan and the enrollment capacity of each plan.
- Plan quality and performance indicators for the benefits under the plan, including:
- Disenrollment rates for Medicare enrollees electing to receive benefits through the plan for the previous two years.
- Information on Medicare enrollee satisfaction.
- Information on health outcomes.
- To comply with all applicable provider requirements, including provider certification requirements, anti-discrimination requirements, provider participation and consultation requirements, the prohibition on interference with provider advice, limits on provider indemnification, rules governing payments to providers and limits on physician incentive plans and preclusion list requirements.
- To ensure any services or other activity performed by a first tier, downstream and related entity, in accordance with a contract, are consistent and comply with the MA organization’s contractual obligations.