Module 6
Regulatory & Contracting Basics
Navigate the regulatory environment Belong operates in — from CMS contracts to HIPAA compliance to health plan agreements.
Key Regulatory Frameworks
42 CFR Part 422
CMS regulation governing Medicare Advantage — enrollment, benefits, quality, and financial requirements.
ACO REACH Program Rules
CMS Innovation Center rules defining benchmark methodology, risk-sharing, and participant obligations.
HIPAA / HITECH
Federal privacy and security rules governing PHI use, data sharing, and breach notification.
State Insurance Regulations
State-level requirements affecting plan licensure, network adequacy, and member communications.
Risk-Sharing Contract Structures
| Structure | Upside | Downside | Best For |
|---|---|---|---|
| Shared Savings Only | Up to 50% of savings | None | Early-stage ACOs |
| Partial Risk | Up to 60% | Capped at 5–10% | Established ACOs |
| Full Risk | Up to 100% of margin | Unlimited | Mature risk-bearers like Belong |
| Global Capitation (MA) | Full premium margin | Full cost responsibility | Experienced MA operators |
Knowledge Check
Question 1 of 3
In an ACO REACH full-risk contract, Belong's downside exposure means:
💡 Reflection: What's the biggest regulatory risk Belong faces as it scales into new markets? How would you mitigate it?