Medicare Advantage Conditions of Participation (COPS)

VII. Key Issues: Regulation & Reform >> B. Health Care Regulation >> Health Insurance Regulation >> Medicare Advantage COPS (last updated: 2.9.17)


The M+C program was created as Part C of Medicare under the Balanced Budget Act of 1997 (P.L. 105-33). The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173) established the Medicare Advantage program under Part C of Medicare, essentially renaming the program while also implementing a series of programmatic reforms.The conditions of participation relate to data reporting requirements, enrollment and marketing, member grievances and other aspects of providing high quality care to plan members.  The Duke Center for Health Policy has developed a draft working paper on the benefits and costs of Medicare + Choice conditions of participation.

Benefits of MA Plans

Medicare Advantage plans offer Medicare beneficiaries a holistic approach to their care, combining medical and drug coverage into an integrated private health care plan.

  • Broader Benefits. MA plans often include benefits that traditional Medicare does not, such as wellness programs, as well as routine vision and dental care.
  • Satisfaction/Outcomes. MA plans are able to achieve higher satisfaction and better outcomes for an equal or lower cost because they better manage care and effectively negotiate costs for everything from doctors and hospitals to prescription medicines.
  • Spillover Benefits. A recent study in the journal Health Affairs found that the greater the penetration of Medicare Advantage in a particular market, the lower the costs for traditional Medicare patients there.
  • Market Penetration. An increasing number of seniors are choosing MA over traditional Medicare and have a variety of choices of competing private plans within MA to choose from.



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