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Title 42 → Chapter IV → Subchapter D → Part 457 → Subpart L → Subject Group

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

MCO, PIHP, and PAHP Standards

§457.1230 Access standards.

(a) Availability of services. The State must ensure that the services are available and accessible to enrollees in accordance with the terms of §438.206 of this chapter.

(b) Assurances of adequate capacity and services. The State must ensure, through its contracts, that each MCO, PIHP and PAHP has adequate capacity to serve the expected enrollment in accordance with the terms of §438.207 of this chapter.

(c) Coordination and continuity of care. The State must ensure, through its contracts, that each MCO, PIHP and PAHP complies with the coordination and continuity of care requirements in accordance with the terms of §438.208 of this chapter, except that the applicability date in §438.208(d) does not apply.

(d) Coverage and authorization of services. The State must ensure, through its contracts, that each MCO, PIHP or PAHP complies with the coverage and authorization of services requirements in accordance with the terms of §438.210 of this chapter, except that the following do not apply: §438.210(a)(5) of this chapter (related to medical necessity standard); §438.210(b)(2)(iii) of this chapter (related to authorizing LTSS), and §438.210(f) (relating to the applicability date).

[81 FR 27897, May 6, 2016, as amended at 82 FR 40, Jan. 3, 2017]

§457.1233 Structure and operation standards.

(a) Provider selection. The State must ensure, through its contracts, that each MCO, PIHP or PAHP complies with the provider selection requirements as provided in §438.214 of this chapter.

(b) Subcontractual relationships and delegation. The State must ensure, through its contracts, that each MCO, PIHP, PAHP, and PCCM entity complies with the subcontractual relationships and delegation requirements as provided in §438.230 of this chapter.

(c) Practice guidelines. The state must ensure, through its contracts, that each MCO and, when applicable, each PIHP and PAHP, complies with the practice guidelines requirements as provided in §438.236 of this chapter.

(d) Health information systems. The State must ensure, through its contracts, that each MCO, PIHP, and PAHP complies with the health information systems requirements as provided in §438.242 of this chapter, except that the applicability date in §438.242(e) of this chapter does not apply. The State is required to submit enrollee encounter data to CMS in accordance with §438.818 of this chapter.

(e) Privacy protections. The state must ensure, through its contracts, that each MCO, PIHP, and PAHP complies with the privacy protections as provided in §457.1110.

[81 FR 27897, May 6, 2016, as amended at 82 FR 40, Jan. 3, 2017; 85 FR 25637, May 1, 2020; 85 FR 72842, Nov. 13, 2020]

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