About GPO   |   Newsroom/Media   |   Congressional Relations   |   Inspector General   |   Careers   |   Contact   |   askGPO   |   Help  
 
Home   |   Customers   |   Vendors   |   Libraries  

The Electronic Code of Federal Regulations (e-CFR) is a regularly updated, unofficial editorial compilation of CFR material and Federal Register amendments produced by the National Archives and Records Administration's Office of the Federal Register (OFR) and the Government Printing Office.

Parallel Table of Authorities and Rules for the Code of Federal Regulations and the United States Code
Text | PDF

Find, review, and submit comments on Federal rules that are open for comment and published in the Federal Register using Regulations.gov.

Purchase individual CFR titles from the U.S. Government Online Bookstore.

Find issues of the CFR (including issues prior to 1996) at a local Federal depository library.

[2]
 
 

Electronic Code of Federal Regulations

blue pill

e-CFR Data is current as of September 18, 2014

Title 42Chapter IVSubchapter CPart 438


TITLE 42—Public Health

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

SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS

PART 438—MANAGED CARE

rule

Subpart A—GENERAL PROVISIONS

§438.1
Basis and scope.
§438.2
Definitions.
§438.6
Contract requirements.
§438.8
Provisions that apply to PIHPs and PAHPs.
§438.10
Information requirements.
§438.12
Provider discrimination prohibited.
rule

Subpart B—STATE RESPONSIBILITIES

§438.50
State Plan requirements.
§438.52
Choice of MCOs, PIHPs, PAHPs, and PCCMs.
§438.56
Disenrollment: Requirements and limitations.
§438.58
Conflict of interest safeguards.
§438.60
Limit on payment to other providers.
§438.62
Continued services to beneficiaries.
§438.66
Monitoring procedures.
rule

Subpart C—ENROLLEE RIGHTS AND PROTECTIONS

§438.100
Enrollee rights.
§438.102
Provider-enrollee communications.
§438.104
Marketing activities.
§438.106
Liability for payment.
§438.108
Cost sharing.
§438.114
Emergency and poststabilization services.
§438.116
Solvency standards.
rule

Subpart D—QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT

§438.200
Scope.
§438.202
State responsibilities.
§438.204
Elements of State quality strategies.

Access Standards

§438.206
Availability of services.
§438.207
Assurances of adequate capacity and services.
§438.208
Coordination and continuity of care.
§438.210
Coverage and authorization of services.

Structure and Operation Standards

§438.214
Provider selection.
§438.218
Enrollee information.
§438.224
Confidentiality.
§438.226
Enrollment and disenrollment.
§438.228
Grievance systems.
§438.230
Subcontractual relationships and delegation.

Measurement and Improvement Standards

§438.236
Practice guidelines.
§438.240
Quality assessment and performance improvement program.
§438.242
Health information systems.
rule

Subpart E—EXTERNAL QUALITY REVIEW

§438.310
Basis, scope, and applicability.
§438.320
Definitions.
§438.350
State responsibilities.
§438.352
External quality review protocols.
§438.354
Qualifications of external quality review organizations.
§438.356
State contract options.
§438.358
Activities related to external quality review.
§438.360
Nonduplication of mandatory activities.
§438.362
Exemption from external quality review.
§438.364
External quality review results.
§438.370
Federal financial participation.
rule

Subpart F—GRIEVANCE SYSTEM

§438.400
Statutory basis and definitions.
§438.402
General requirements.
§438.404
Notice of action.
§438.406
Handling of grievances and appeals.
§438.408
Resolution and notification: Grievances and appeals.
§438.410
Expedited resolution of appeals.
§438.414
Information about the grievance system to providers and subcontractors.
§438.416
Recordkeeping and reporting requirements.
§438.420
Continuation of benefits while the MCO or PIHP appeal and the State fair hearing are pending.
§438.424
Effectuation of reversed appeal resolutions.
rule

Subpart G—[RESERVED]

rule

Subpart H—CERTIFICATIONS AND PROGRAM INTEGRITY

§438.600
Statutory basis.
§438.602
Basic rule.
§438.604
Data that must be certified.
§438.606
Source, content, and timing of certification.
§438.608
Program integrity requirements.
§438.610
Prohibited affiliations with individuals debarred by Federal agencies.
rule

Subpart I—SANCTIONS

§438.700
Basis for imposition of sanctions.
§438.702
Types of intermediate sanctions.
§438.704
Amounts of civil money penalties.
§438.706
Special rules for temporary management.
§438.708
Termination of an MCO or PCCM contract.
§438.710
Due process: Notice of sanction and pre-termination hearing.
§438.722
Disenrollment during termination hearing process.
§438.724
Notice to CMS.
§438.726
State plan requirement.
§438.730
Sanction by CMS: Special rules for MCOs
rule

Subpart J—CONDITIONS FOR FEDERAL FINANCIAL PARTICIPATION

§438.802
Basic requirements.
§438.804
Primary care provider payment increases.
§438.806
Prior approval.
§438.808
Exclusion of entities.
§438.810
Expenditures for enrollment broker services.
§438.812
Costs under risk and nonrisk contracts.


For questions or comments regarding e-CFR editorial content, features, or design, email ecfr@nara.gov.
For questions concerning e-CFR programming and delivery issues, email webteam@gpo.gov.