[Title 42 CFR 422.208]
[Code of Federal Regulations (annual edition) - October 1, 2007 Edition]
[Title 42 - PUBLIC HEALTH]
[Chapter IV - CENTERS FOR MEDICARE]
[Subchapter A - GENERAL PROVISIONS]
[Part 422 - MEDICARE ADVANTAGE PROGRAM]
[Subpart E - Relationships With Providers]
[Sec. 422.208 - Physician incentive plans: requirements and limitations.]
[From the U.S. Government Printing Office]
42PUBLIC HEALTH32007-10-012007-10-01falsePhysician incentive plans: requirements and limitations.422.208Sec. 422.208PUBLIC HEALTHCENTERS FOR MEDICAREGENERAL PROVISIONSMEDICARE ADVANTAGE PROGRAMRelationships With Providers
Sec. 422.208 Physician incentive plans: requirements and limitations.
(a) Definitions. In this subpart, the following definitions apply:
Bonus means a payment made to a physician or physician group beyond
any salary, fee-for-service payments, capitation, or returned withhold.
Capitation means a set dollar payment per patient per unit of time
(usually per month) paid to a physician or physician group to cover a
specified set of services and administrative costs without regard to the
actual number of services provided. The services covered may include the
physician's own services, referral services, or all medical services.
Physician group means a partnership, association, corporation,
individual practice association, or other group of physicians that
distributes income from the practice among members. An individual
practice association is defined as a physician group for this section
only if it is composed of individual physicians and has no subcontracts
with physician groups.
Physician incentive plan means any compensation arrangement to pay a
physician or physician group that may directly or indirectly have the
effect of reducing or limiting the services provided to any plan
enrollee.
Potential payments means the maximum payments possible to physicians
or physician groups including payments for services they furnish
directly, and additional payments based on use and costs of referral
services, such as withholds, bonuses, capitation, or any other
compensation to the physician or physician group. Bonuses and other
compensation that are not based on use of referrals, such as quality of
care furnished, patient satisfaction or committee participation, are not
considered payments in the determination of substantial financial risk.
Referral services means any specialty, inpatient, outpatient, or
laboratory services that a physician or physician group orders or
arranges, but does not furnish directly.
Risk threshold means the maximum risk, if the risk is based on
referral services, to which a physician or physician group may be
exposed under a physician incentive plan without being at substantial
financial risk. This is set at 25 percent risk.
Substantial financial risk, for purposes of this section, means risk
for referral services that exceeds the risk threshold.
Withhold means a percentage of payments or set dollar amounts
deducted from a physician's service fee, capitation, or salary payment,
and that may or may not be returned to the physician, depending on
specific predetermined factors.
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(b) Applicability. The requirements in this section apply to an MA
organization and any of its subcontracting arrangements that utilize a
physician incentive plan in their payment arrangements with individual
physicians or physician groups. Subcontracting arrangements may include
an intermediate entity, which includes but is not limited to, an
individual practice association that contracts with one or more
physician groups or any other organized group such as those specified in
Sec. 422.4.
(c) Basic requirements. Any physician incentive plan operated by an
MA organization must meet the following requirements:
(1) The MA organization makes no specific payment, directly or
indirectly, to a physician or physician group as an inducement to reduce
or limit medically necessary services furnished to any particular
enrollee. Indirect payments may include offerings of monetary value
(such as stock options or waivers of debt) measured in the present or
future.
(2) If the physician incentive plan places a physician or physician
group at substantial financial risk (as determined under paragraph (d)
of this section) for services that the physician or physician group does
not furnish itself, the MA organization must assure that all physicians
and physician groups at substantial financial risk have either aggregate
or per-patient stop-loss protection in accordance with paragraph (f) of
this section.
(3) For all physician incentive plans, the MA organization provides
to CMS the information specified in Sec. 422.210.
(d) Determination of substantial financial risk--(1) Basis.
Substantial financial risk occurs when risk is based on the use or costs
of referral services, and that risk exceeds the risk threshold. Payments
based on other factors, such as quality of care furnished, are not
considered in this determination.
(2) Risk threshold. The risk threshold is 25 percent of potential
payments.
(3) Arrangements that cause substantial financial risk. The
following incentive arrangements cause substantial financial risk within
the meaning of this section, if the physician's or physician group's
patient panel size is not greater than 25,000 patients, as shown in the
table at paragraph (f)(2)(iii) of this section:
(i) Withholds greater than 25 percent of potential payments.
(ii) Withholds less than 25 percent of potential payments if the
physician or physician group is potentially liable for amounts exceeding
25 percent of potential payments.
(iii) Bonuses that are greater than 33 percent of potential payments
minus the bonus.
(iv) Withholds plus bonuses if the withholds plus bonuses equal more
than 25 percent of potential payments. The threshold bonus percentage
for a particular withhold percentage may be calculated using the
formula--Withhold % = -0.75 (Bonus %) +25%.
(v) Capitation arrangements, if--
(A) The difference between the maximum potential payments and the
minimum potential payments is more than 25 percent of the maximum
potential payments;
(B) The maximum and minimum potential payments are not clearly
explained in the contract with the physician or physician group.
(vi) Any other incentive arrangements that have the potential to
hold a physician or physician group liable for more than 25 percent of
potential payments.
(e) Prohibition for private MA fee-for-service plans. An MA fee-for-
service plan may not operate a physician incentive plan.
(f) Stop-loss protection requirements--(1) Basic rule. The MA
organization must assure that all physicians and physician groups at
substantial financial risk have either aggregate or per-patient stop-
loss protection in accordance with the following requirements:
(2) Specific requirements. (i) Aggregate stop-loss protection must
cover 90 percent of the costs of referral services that exceed 25
percent of potential payments.
(ii) For per-patient stop-loss protection if the stop-loss
protection provided is on a per-patient basis, the stop-loss limit
(deductible) per patient must be determined based on the size
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of the patient panel and may be a combined policy or consist of separate
policies for professional services and institutional services. In
determining patient panel size, the patients may be pooled in accordance
with paragraph (g) of this section.
(iii) Stop-loss protection must cover 90 percent of the costs of
referral services that exceed the per patient deductible limit. The per-
patient stop-loss deductible limits are as follows:
----------------------------------------------------------------------------------------------------------------
Separate Separate
Panel size Single combined institutional professional
deductible deductible deductible
----------------------------------------------------------------------------------------------------------------
1-1,000................................................ $6,000 $10,000 $3,000
1,001-5,000............................................ 30,000 40,000 10,000
5,001-8,000............................................ 40,000 60,000 15,000
8,001-10,000........................................... 75,000 100,000 20,000
10,001-25,000.......................................... 150,000 200,000 25,000
25,000...................................... (\1\) (\1\) (\1\)
----------------------------------------------------------------------------------------------------------------
\1\ None.
(g) Pooling of patients. Any entity that meets the pooling
conditions of this section may pool commercial, Medicare, and Medicaid
enrollees or the enrollees of several MA organizations with which a
physician or physician group has contracts. The conditions for pooling
are as follows:
(1) It is otherwise consistent with the relevant contracts governing
the compensation arrangements for the physician or physician group.
(2) The physician or physician group is at risk for referral
services with respect to each of the categories of patients being
pooled.
(3) The terms of the compensation arrangements permit the physician
or physician group to spread the risk across the categories of patients
being pooled.
(4) The distribution of payments to physicians from the risk pool is
not calculated separately by patient category.
(5) The terms of the risk borne by the physician or physician group
are comparable for all categories of patients being pooled.
(h) Sanctions. An MA organization that fails to comply with the
requirements of this section is subject to intermediate sanctions under
subpart O of this part.
[63 FR 35085, June 26, 1998, as amended at 65 FR 40325, June 29, 2000;
70 FR 4724, Jan. 28, 2005; 70 FR 52026, Sept. 1, 2005]