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Electronic Code of Federal Regulations

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e-CFR Data is current as of October 17, 2014

Title 42Chapter IVSubchapter BPart 417


TITLE 42—Public Health

CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED)

SUBCHAPTER B—MEDICARE PROGRAM (CONTINUED)

PART 417—HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS

rule

Subpart A—GENERAL PROVISIONS

§417.1
Definitions.
§417.2
Basis and scope.
rule

Subpart B—QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS: SERVICES

§417.101
Health benefits plan: Basic health services.
§417.102
Health benefits plan: Supplemental health services.
§417.103
Providers of basic and supplemental health services.
§417.104
Payment for basic health services.
§417.105
Payment for supplemental health services.
§417.106
Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services.
rule

Subpart C—QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS: ORGANIZATION AND OPERATION

§417.120
Fiscally sound operation and assumption of financial risk.
§417.122
Protection of enrollees.
§417.124
Administration and management.
§417.126
Recordkeeping and reporting requirements.
rule

Subpart D—APPLICATION FOR FEDERAL QUALIFICATION

§417.140
Scope.
§417.142
Requirements for qualification.
§417.143
Application requirements.
§417.144
Evaluation and determination procedures.
rule

Subpart E—INCLUSION OF QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS IN EMPLOYEE HEALTH BENEFITS PLANS

§417.150
Definitions.
§417.151
Applicability.
§417.153
Offer of HMO alternative.
§417.155
How the HMO option must be included in the health benefits plan.
§417.156
When the HMO must be offered to employees.
§417.157
Contributions for the HMO alternative.
§417.158
Payroll deductions.
§417.159
Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway Labor Act.
rule

Subpart F—CONTINUED REGULATION OF FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS

§417.160
Applicability.
§417.161
Compliance with assurances.
§417.162
Reporting requirements.
§417.163
Enforcement procedures.
§417.164
Effect of revocation of qualification on inclusion in employee's health benefit plans.
§417.165
Reapplication for qualification.
§417.166
Waiver of assurances.
rule

Subparts G-I [Reserved]

rule

Subpart J—QUALIFYING CONDITIONS FOR MEDICARE CONTRACTS

§417.400
Basis and scope.
§417.401
Definitions.
§417.402
Effective date of initial regulations.
§417.404
General requirements.
§417.406
Application and determination.
§417.407
Requirements for a Competitive Medical Plan (CMP).
§417.408
Contract application process.
§417.410
Qualifying conditions: General rules.
§417.412
Qualifying condition: Administration and management.
§417.413
Qualifying condition: Operating experience and enrollment.
§417.414
Qualifying condition: Range of services.
§417.416
Qualifying condition: Furnishing of services.
§417.418
Qualifying condition: Quality assurance program.
rule

Subpart K—ENROLLMENT, ENTITLEMENT, AND DISENROLLMENT UNDER MEDICARE CONTRACT

§417.420
Basic rules on enrollment and entitlement.
§417.422
Eligibility to enroll in an HMO or CMP.
§417.423
Special rules: ESRD and hospice patients.
§417.424
Denial of enrollment.
§417.426
Open enrollment requirements.
§417.427
Extending MA and Part D program disclosure requirements to section 1876 cost contract plans.
§417.428
Marketing activities.
§417.430
Application procedures.
§417.432
Conversion of enrollment.
§417.434
Reenrollment.
§417.436
Rules for enrollees.
§417.440
Entitlement to health care services from an HMO or CMP.
§417.442
Risk HMO's and CMP's: Conditions for provision of additional benefits.
§417.444
Special rules for certain enrollees of risk HMOs and CMPs.
§417.446
[Reserved]
§417.448
Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.
§417.450
Effective date of coverage.
§417.452
Liability of Medicare enrollees.
§417.454
Charges to Medicare enrollees.
§417.456
Refunds to Medicare enrollees.
§417.458
Recoupment of uncollected deductible and coinsurance amounts.
§417.460
Disenrollment of beneficiaries by an HMO or CMP.
§417.461
Disenrollment by the enrollee.
§417.464
End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract.
rule

Subpart L—MEDICARE CONTRACT REQUIREMENTS

§417.470
Basis and scope.
§417.472
Basic contract requirements.
§417.474
Effective date and term of contract.
§417.476
Waived conditions.
§417.478
Requirements of other laws and regulations.
§417.479
Requirements for physician incentive plans.
§417.480
Maintenance of records: Cost HMOs and CMPs.
§417.481
Maintenance of records: Risk HMOs and CMPs.
§417.482
Access to facilities and records.
§417.484
Requirement applicable to related entities.
§417.486
Disclosure of information and confidentiality.
§417.488
Notice of termination and of available alternatives: Risk contract.
§417.490
Renewal of contract.
§417.492
Nonrenewal of contract.
§417.494
Modification or termination of contract.
§417.500
Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.
rule

Subpart M—CHANGE OF OWNERSHIP AND LEASING OF FACILITIES: EFFECT ON MEDICARE CONTRACT

§417.520
Effect on HMO and CMP contracts.
rule

Subpart N—MEDICARE PAYMENT TO HMOS AND CMPS: GENERAL RULES

§417.524
Payment to HMOs or CMPs: General.
§417.526
Payment for covered services.
§417.528
Payment when Medicare is not primary payer.
rule

Subpart O—MEDICARE PAYMENT: COST BASIS

§417.530
Basis and scope.
§417.531
Hospice care services.
§417.532
General considerations.
§417.533
Part B carrier responsibilities.
§417.534
Allowable costs.
§417.536
Cost payment principles.
§417.538
Enrollment and marketing costs.
§417.540
Enrollment costs.
§417.542
Reinsurance costs.
§417.544
Physicians' services furnished directly by the HMO or CMP.
§417.546
Physicians' services and other Part B supplier services furnished under arrangements.
§417.548
Provider services through arrangements.
§417.550
Special Medicare program requirements.
§417.552
Cost apportionment: General provisions.
§417.554
Apportionment: Provider services furnished directly by the HMO or CMP.
§417.556
Apportionment: Provider services furnished by the HMO or CMP through arrangements with others.
§417.558
Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility.
§417.560
Apportionment: Part B physician and supplier services.
§417.564
Apportionment and allocation of administrative and general costs.
§417.566
Other methods of allocation and apportionment.
§417.568
Adequate financial records, statistical data, and cost finding.
§417.570
Interim per capita payments.
§417.572
Budget and enrollment forecast and interim reports.
§417.574
Interim settlement.
§417.576
Final settlement.
rule

Subpart P—MEDICARE PAYMENT: RISK BASIS

§417.580
Basis and scope.
§417.582
Definitions.
§417.584
Payment to HMOs or CMPs with risk contracts.
§417.585
Special rules: Hospice care.
§417.588
Computation of adjusted average per capita cost (AAPCC).
§417.590
Computation of the average of the per capita rates of payment.
§417.592
Additional benefits requirement.
§417.594
Computation of adjusted community rate (ACR).
§417.596
Establishment of a benefit stabilization fund.
§417.597
Withdrawal from a benefit stabilization fund.
§417.598
Annual enrollment reconciliation.
rule

Subpart Q—BENEFICIARY APPEALS

§417.600
Basis and scope.
rule

Subpart R—MEDICARE CONTRACT APPEALS

§417.640
Applicability.
rule

Subparts S-T [Reserved]

rule

Subpart U—HEALTH CARE PREPAYMENT PLANS

§417.800
Payment to HCPPs: Definitions and basic rules.
§417.801
Agreements between CMS and health care prepayment plans.
§417.802
Allowable costs.
§417.804
Cost apportionment.
§417.806
Financial records, statistical data, and cost finding.
§417.808
Interim per capita payments.
§417.810
Final settlement.
§417.830
Scope of regulations on beneficiary appeals.
§417.832
Applicability of requirements and procedures.
§417.834
Responsibility for establishing administrative review procedures.
§417.836
Written description of administrative review procedures.
§417.838
Organization determinations.
§417.840
Administrative review procedures.
rule

Subpart V—ADMINISTRATION OF OUTSTANDING LOANS AND LOAN GUARANTEES

§417.910
Applicability.
§417.911
Definitions.
§417.920
Planning and initial development.
§417.930
Initial costs of operation.
§417.931
[Reserved]
§417.934
Reserve requirement.
§417.937
Loan and loan guarantee provisions.
§417.940
Civil action to enforce compliance with assurances.


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