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e-CFR data is current as of March 3, 2021

Title 42Chapter IVSubchapter DPart 457Subpart L → §457.1270


Title 42: Public Health
PART 457—ALLOTMENTS AND GRANTS TO STATES
Subpart L—Managed Care


§457.1270   Sanctions.

(a) General. The State must comply with §§438.700 through 438.704, 438.706(c) and (d), and 438.708 through 438.730 of this chapter.

(b) Optional imposition of temporary management. Except as provided in paragraph (c) of this section, the State may impose temporary management under §438.702(a)(2) of this chapter as referenced in paragraph (a) of this section, only if it finds (through onsite surveys, enrollee or other complaints, financial status, or any other source) any of the following:

(1) There is continued egregious behavior by the MCO, including but not limited to behavior that is described in §438.700 of this chapter (as referenced in paragraph (a) of this section), or that is contrary to any of the requirements of this subpart.

(2) There is substantial risk to enrollees' health.

(3) The sanction is necessary to ensure the health of the MCO's enrollees—

(i) While improvements are made to remedy violations under §438.700 of this chapter as referenced in paragraph (a) of this section.

(ii) Until there is an orderly termination or reorganization of the MCO.

(c) Required imposition of temporary management. The State must impose temporary management (regardless of any other sanction that may be imposed) if it finds that an MCO has repeatedly failed to meet substantive requirements in this subpart. The State must also grant enrollees the right to terminate enrollment without cause, as described in §438.702(a)(3) of this chapter as referenced in paragraph (a) of this section, and must notify the affected enrollees of their right to terminate enrollment.

[85 FR 72843, Nov. 13, 2020]

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