Last updated: November 2026
A first Medicare Advantage (MA) application is the filing an organization makes to qualify for a CMS contract as an MA organization, and CMS will not accept it unless the organization first submitted a timely Notice of Intent to Apply under 42 CFR 422.501. It is for provider-sponsored and startup plans preparing their first application. Integral Healthcare Solutions (IHS) is a consulting firm that drafts the policy and procedure set, organization charts, compliance program documents and readiness calendar; the plan's officers adopt them and submit the application.
This is compliance services work, one of three IHS practice lines alongside accreditation consulting and program development.
What is a Medicare Advantage new-plan application?
It is the certified application an entity completes so CMS can decide whether it qualifies as an MA organization. The Part C rules are in three sections: 42 CFR 422.501 (application requirements), 42 CFR 422.502 (evaluation and determination) and 42 CFR 422.503 (conditions to contract). We checked these sections and 422.514 against the eCFR text built November 4, 2026 (Title 42 last amended October 8, 2026), on November 5, 2026.
The notice comes first
"An organization submitting an application under this section for a particular contract year must first submit a completed Notice of Intent to Apply by the date established by CMS. CMS will not accept applications from organizations that do not first submit a timely Notice of Intent to Apply." (422.501(b)(1)). The notice is not a commitment: "Submitting a Notice of Intent to Apply does not bind that organization to submit an application for the applicable contract year." (b)(2). A decision not to apply after filing the notice will not form the basis of any CMS action against the organization ((b)(3)).
What the application must contain
The applicant, or an individual authorized to act for it, must fully complete all parts of a certified application in the form and manner CMS requires (422.501(c)(1)). The listed items include:
- "Documentation of appropriate State licensure or State certification that the entity is able to offer health insurance or health benefits coverage that meets State-specified standards applicable to MA plans, and is authorized by the State to accept prepaid capitation for providing, arranging, or paying for the comprehensive health care services to be offered under the MA contract." (c)(1)(i).
- For regional plans, documentation of application for licensure in each State of the region where the organization is not yet licensed ((c)(1)(ii)); for special needs plans, documentation that the entity meets the sections listed in (c)(1)(iii).
- "Documentation that payment for health care services or items is not being and will not be made to individuals and entities included on the preclusion list, defined in § 422.2." (c)(1)(iv).
How CMS reviews it
"CMS is responsible for determining whether an entity qualifies as an MA organization and whether proposed MA plans meet the requirements of this part." (422.501(d)(1)). Three rules matter most to a new applicant:
- "An application is substantially incomplete when the submission as of the deadline for applications established by CMS is missing content or responsive materials for one or more sections of the application form required by CMS." (422.502(a)(3)(ii)). CMS does not evaluate such an application or issue a notice of determination, and that finding is not appealable under subpart N ((a)(3)(i), (iii)).
- "In the absence of 12 months of performance history, CMS may deny an application based on a lack of information available to determine an applicant's capacity to comply with the requirements of the MA program." (422.502(b)(2)).
- "Within 10 days from the intent to deny, the applicant must respond in writing to the issues or other matters that were the basis for CMS' preliminary finding and must revise its application to remedy any defects CMS identified." (422.502(c)(2)(ii)). CMS denies the application if no revised application arrives within 10 days of the notice, or if after a timely revision the applicant still does not appear qualified or has not given CMS enough information ((c)(2)(iii)).
Conditions to contract
Under 422.503(b), the entity must also be licensed by the State as a risk bearing entity in each State where it seeks to offer an MA plan, and meet the minimum enrollment rules of 42 CFR 422.514 unless waived. The minimum is at least 5,000 enrollees (1,500 for a provider-sponsored organization, or PSO), with lower figures for organizations that primarily serve individuals outside urbanized areas (for a PSO, one meeting 422.352(c)). CMS may waive the minimum for the first 3 years of the contract if the applicant shows, to CMS's satisfaction, that it can administer the contract and manage the risk (422.514(b)). Administrative arrangements must satisfy CMS, shown by at least a policy making body, an executive manager whose appointment and removal it controls, personnel and systems sufficient to run the organization, a fidelity bond and CMS-approved insurance or other arrangements ((b)(4)).
The compliance program
The organization must "Adopt and implement an effective compliance program, which must include measures that prevent, detect, and correct non-compliance with CMS' program requirements as well as measures that prevent, detect, and correct fraud, waste, and abuse." (422.503(b)(4)(vi)). Its seven minimum core requirements are written policies, procedures and standards of conduct; a compliance officer (an employee of the MA organization, parent or affiliate, not of a first tier, downstream or related entity) and committee reporting directly to the chief executive or senior management; training at least annually and at orientation; confidential lines of communication with a method for anonymous good faith reporting; well-publicized disciplinary standards; routine monitoring and auditing; and prompt response, investigation and correction ((vi)(A)-(G)).
We did not open the current-year CMS application materials, so this page states no dates; get them from CMS.
Who needs it and what triggers it
Provider-sponsored and startup plans preparing a first application need it. The triggers are a decision to apply for a contract year, which requires a timely Notice of Intent to Apply (422.501(b)(1)), and a policy set, governance documents or compliance program that do not yet exist in adoptable form.
How IHS helps
Thomas G. Goddard, JD, PhD, leads the work.
- Build a requirement checklist from the current CMS application and 422.501 through 422.503.
- Map your existing policies and procedures to each requirement.
- Draft the missing policies, organization charts, governance documents and compliance program for your officers to adopt.
- Run a mock review of the draft application for sections that could leave it substantially incomplete.
- Build a readiness calendar keyed to the CMS dates, with time held for a 10-day intent-to-deny response.
What you supply. Your officers adopt the documents and submit the notice and application. You supply licensure, the actuarial, network and operations content, the bond and insurance, and counsel for licensure and corporate structure.
The real limit. IHS drafts; your officers file and deal with CMS. Bids, actuarial and network adequacy work are outside IHS scope.
What to have ready
- The current Notice of Intent to Apply date from CMS (422.501(b)(1)).
- The individual authorized to act for the entity (422.501(c)(1)).
- State licensure or certification documentation, including authority to accept prepaid capitation for the comprehensive services under the MA contract (422.501(c)(1)(i)), and a risk bearing entity license in each State where you seek to offer an MA plan (422.503(b)(2)).
- A payee screening process and record for the preclusion list (422.501(c)(1)(iv)).
- Enrollment projections against 422.514, or support for a waiver request (422.514(b)).
- Policy making body, executive manager, personnel and systems, fidelity bond, and CMS-approved insurance or other arrangements (422.503(b)(4)(i)-(v)).
- An adopted and implemented compliance program covering all seven core requirements (422.503(b)(4)(vi)).
- The policy and procedure set, mapped to every section of the current application form.
The free introductory call turns that list into a calendar.
How it compares
Part D drug coverage turns on plan type under 42 CFR 422.4(c):
| Plan type | Part D coverage under 422.4(c) |
|---|---|
| Coordinated care plan | Must offer qualified Part D coverage meeting 423.104 in that plan or in another MA plan in the same area |
| Medical savings account (MSA) plan | May not offer drug coverage beyond what Parts A and B require |
| Private fee-for-service plan | May choose to offer qualified Part D coverage meeting 423.104 |
42 CFR 423.502 sets a separate Notice of Intent to Apply and application for an entity seeking to contract as a Part D plan sponsor. This page covers the Part C rules.
What it costs
The cost has three parts. Authority fees: the sections we opened set no CMS application fee, and we did not verify whether any fee applies, so verify with CMS. Consulting: IHS scopes each engagement after a free introductory call; scope moves with how much of the policy set exists and how far along licensure and the compliance program are. Internal staff time: your officers, counsel and leads review, adopt and file.
What this is not
- It is not legal advice. IHS is a consulting firm, not a law firm, and counsel handles licensure and corporate structure.
- It is not a bid, actuarial or network adequacy service, and it does not predict or influence CMS's decision.
- IHS does not file the notice or the application and does not deal with CMS.
Frequently asked questions
What must happen before CMS accepts a Medicare Advantage application?
The organization must first submit a completed Notice of Intent to Apply by the date CMS sets for that contract year. "CMS will not accept applications from organizations that do not first submit a timely Notice of Intent to Apply." (42 CFR 422.501(b)(1)).
Is the Notice of Intent to Apply binding?
No. It does not bind the organization to submit an application for the applicable contract year, and a decision not to apply will not form the basis of any CMS action against it (42 CFR 422.501(b)(2)-(3)).
What state documentation does a new Medicare Advantage plan need?
Documentation of appropriate State licensure or State certification that the entity can offer health insurance or health benefits coverage meeting State-specified standards for MA plans, and that the State authorizes it to accept prepaid capitation for the comprehensive health care services offered under the MA contract (42 CFR 422.501(c)(1)(i)). To contract, it must also be licensed as a risk bearing entity in each State where it seeks to offer an MA plan (422.503(b)(2)).
What is the preclusion list documentation?
Documentation that payment for health care services or items is not being and will not be made to individuals and entities on the preclusion list defined in 422.2 (42 CFR 422.501(c)(1)(iv)). The plan needs a payee screening process and a record of it; IHS drafts the procedure.
What happens if a section of the application is missing at the deadline?
An application is substantially incomplete when, as of the CMS deadline, it is missing content or responsive materials for one or more sections of the required application form. CMS does not evaluate it or issue a notice of determination, and that finding is not appealable under subpart N (42 CFR 422.502(a)(3)).
What happens after a notice of intent to deny?
The applicant has 10 days to respond in writing and revise its application to remedy the defects (42 CFR 422.502(c)(2)(ii)). CMS denies it if no revision arrives within 10 days of the notice, or if after a timely revision the applicant still does not appear qualified or has not given CMS enough information.
What happens if CMS denies a new-plan application?
It may not be resubmitted until the beginning of the application cycle for the following contract year (42 CFR 422.501(e)). The denial notice states the reasons and the right to request a hearing (422.502(c)(3)).
What does IHS draft, and what do plan officers submit?
IHS drafts the policy and procedure set, organization charts, governance documents, compliance program documents and the readiness calendar. Your officers adopt them and submit the notice and application.