e-CFR data is current as of October 22, 2020
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
Subpart A—GENERAL PROVISIONS
Subpart B—QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS: SERVICES
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| Health benefits plan: Basic health services. |
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| Health benefits plan: Supplemental health services. |
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| Providers of basic and supplemental health services. |
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| Payment for basic health services. |
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| Payment for supplemental health services. |
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| Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services. |
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Subpart C—QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS: ORGANIZATION AND OPERATION
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| Fiscally sound operation and assumption of financial risk. |
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| Administration and management. |
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| Recordkeeping and reporting requirements. |
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Subpart D—APPLICATION FOR FEDERAL QUALIFICATION
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| Requirements for qualification. |
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| Application requirements. |
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| Evaluation and determination procedures. |
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Subpart E—INCLUSION OF QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS IN EMPLOYEE HEALTH BENEFITS PLANS
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| Offer of HMO alternative. |
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| How the HMO option must be included in the health benefits plan. |
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| When the HMO must be offered to employees. |
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| Contributions for the HMO alternative. |
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| Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway Labor Act. |
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Subpart F—CONTINUED REGULATION OF FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS
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| Compliance with assurances. |
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| Effect of revocation of qualification on inclusion in employee's health benefit plans. |
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| Reapplication for qualification. |
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Subparts G-I [Reserved]
Subpart J—QUALIFYING CONDITIONS FOR MEDICARE CONTRACTS
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| Effective date of initial regulations. |
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| Application and determination. |
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| Requirements for a Competitive Medical Plan (CMP). |
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| Contract application process. |
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| Qualifying conditions: General rules. |
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| Qualifying condition: Administration and management. |
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| Qualifying condition: Operating experience and enrollment. |
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| Qualifying condition: Range of services. |
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| Qualifying condition: Furnishing of services. |
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| Qualifying condition: Quality assurance program. |
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Subpart K—ENROLLMENT, ENTITLEMENT, AND DISENROLLMENT UNDER MEDICARE CONTRACT
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| Basic rules on enrollment and entitlement. |
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| Eligibility to enroll in an HMO or CMP. |
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| Special rules: ESRD and hospice patients. |
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| Open enrollment requirements. |
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| Extending MA and Part D program disclosure requirements to section 1876 cost contract plans. |
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| Conversion of enrollment. |
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| Entitlement to health care services from an HMO or CMP. |
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| Risk HMO's and CMP's: Conditions for provision of additional benefits. |
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| Special rules for certain enrollees of risk HMOs and CMPs. |
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| Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs. |
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| Effective date of coverage. |
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| Liability of Medicare enrollees. |
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| Charges to Medicare enrollees. |
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| Refunds to Medicare enrollees. |
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| Recoupment of uncollected deductible and coinsurance amounts. |
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| Disenrollment of beneficiaries by an HMO or CMP. |
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| Disenrollment by the enrollee. |
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| End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract. |
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Subpart L—MEDICARE CONTRACT REQUIREMENTS
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| Basic contract requirements. |
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| Effective date and term of contract. |
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| Requirements of other laws and regulations. |
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| Requirements for physician incentive plans. |
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| Maintenance of records: Cost HMOs and CMPs. |
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| Maintenance of records: Risk HMOs and CMPs. |
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| Access to facilities and records. |
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| Requirement applicable to related entities. |
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| Disclosure of information and confidentiality. |
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| Notice of termination and of available alternatives: Risk contract. |
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| Modification or termination of contract. |
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| Intermediate sanctions for and civil monetary penalties against HMOs and CMPs. |
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Subpart M—CHANGE OF OWNERSHIP AND LEASING OF FACILITIES: EFFECT ON MEDICARE CONTRACT
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| Effect on HMO and CMP contracts. |
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Subpart N—MEDICARE PAYMENT TO HMOS AND CMPS: GENERAL RULES
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| Payment to HMOs or CMPs: General. |
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| Payment for covered services. |
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| Payment when Medicare is not primary payer. |
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Subpart O—MEDICARE PAYMENT: COST BASIS
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| Part B carrier responsibilities. |
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| Enrollment and marketing costs. |
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| Physicians' services furnished directly by the HMO or CMP. |
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| Physicians' services and other Part B supplier services furnished under arrangements. |
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| Provider services through arrangements. |
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| Special Medicare program requirements. |
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| Cost apportionment: General provisions. |
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| Apportionment: Provider services furnished directly by the HMO or CMP. |
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| Apportionment: Provider services furnished by the HMO or CMP through arrangements with others. |
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| Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility. |
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| Apportionment: Part B physician and supplier services. |
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| Apportionment and allocation of administrative and general costs. |
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| Other methods of allocation and apportionment. |
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| Adequate financial records, statistical data, and cost finding. |
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| Interim per capita payments. |
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| Budget and enrollment forecast and interim reports. |
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Subpart P—MEDICARE PAYMENT: RISK BASIS
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| Payment to HMOs or CMPs with risk contracts. |
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| Special rules: Hospice care. |
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| Computation of adjusted average per capita cost (AAPCC). |
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| Computation of the average of the per capita rates of payment. |
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| Additional benefits requirement. |
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| Computation of adjusted community rate (ACR). |
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| Establishment of a benefit stabilization fund. |
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| Withdrawal from a benefit stabilization fund. |
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| Annual enrollment reconciliation. |
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Subpart Q—BENEFICIARY APPEALS
Subpart R—MEDICARE CONTRACT APPEALS
Subparts S-T [Reserved]
Subpart U—HEALTH CARE PREPAYMENT PLANS
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| Payment to HCPPs: Definitions and basic rules. |
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| Agreements between CMS and health care prepayment plans. |
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| Financial records, statistical data, and cost finding. |
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| Interim per capita payments. |
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| Scope of regulations on beneficiary appeals. |
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| Applicability of requirements and procedures. |
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| Responsibility for establishing administrative review procedures. |
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| Written description of administrative review procedures. |
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| Organization determinations. |
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| Administrative review procedures. |
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Subpart V—ADMINISTRATION OF OUTSTANDING LOANS AND LOAN GUARANTEES
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| Planning and initial development. |
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| Initial costs of operation. |
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| Loan and loan guarantee provisions. |
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| Civil action to enforce compliance with assurances. |
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