e-CFR data is current as of March 4, 2021
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
Subpart A—GENERAL PROVISIONS
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Standard contract requirements. |
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Rate development standards. |
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Special contract provisions related to payment. |
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Rate certification submission. |
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Medical loss ratio (MLR) standards. |
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Provisions that apply to non-emergency medical transportation PAHPs. |
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Information requirements. |
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Provider discrimination prohibited. |
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Requirements that apply to MCO, PIHP, PAHP, PCCM, and PCCM entity contracts involving Indians, Indian health care providers (IHCPs), and Indian managed care entities (IMCEs). |
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Subpart B—STATE RESPONSIBILITIES
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Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities. |
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Disenrollment: Requirements and limitations. |
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Conflict of interest safeguards. |
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Prohibition of additional payments for services covered under MCO, PIHP or PAHP contracts. |
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Continued services to enrollees. |
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State monitoring requirements. |
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Network adequacy standards. |
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Stakeholder engagement when LTSS is delivered through a managed care program. |
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Beneficiary support system. |
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State oversight of the minimum MLR requirement. |
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Subpart C—ENROLLEE RIGHTS AND PROTECTIONS
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Provider-enrollee communications. |
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Member advisory committee. |
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Emergency and poststabilization services. |
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Subpart D—MCO, PIHP AND PAHP STANDARDS
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Availability of services. |
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Assurances of adequate capacity and services. |
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Coordination and continuity of care. |
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Coverage and authorization of services. |
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Grievance and appeal systems. |
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Subcontractual relationships and delegation. |
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Health information systems. |
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Subpart E—QUALITY MEASUREMENT AND IMPROVEMENT; EXTERNAL QUALITY REVIEW
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Basis, scope, and applicability. |
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Quality assessment and performance improvement program. |
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State review of the accreditation status of MCOs, PIHPs, and PAHPs. |
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Medicaid managed care quality rating system. |
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Managed care State quality strategy. |
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External quality review protocols. |
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Qualifications of external quality review organizations. |
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State contract options for external quality review. |
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Activities related to external quality review. |
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Nonduplication of mandatory activities with Medicare or accreditation review. |
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Exemption from external quality review. |
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External quality review results. |
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Federal financial participation (FFP). |
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Subpart F—GRIEVANCE AND APPEAL SYSTEM
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Statutory basis, definitions, and applicability. |
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Timely and adequate notice of adverse benefit determination. |
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Handling of grievances and appeals. |
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Resolution and notification: Grievances and appeals. |
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Expedited resolution of appeals. |
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Information about the grievance and appeal system to providers and subcontractors. |
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Recordkeeping requirements. |
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Continuation of benefits while the MCO, PIHP, or PAHP appeal and the State fair hearing are pending. |
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Effectuation of reversed appeal resolutions. |
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Subpart G—[RESERVED]
Subpart H—ADDITIONAL PROGRAM INTEGRITY SAFEGUARDS
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Statutory basis, basic rule, and applicability. |
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Data, information, and documentation that must be submitted. |
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Source, content, and timing of certification. |
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Program integrity requirements under the contract. |
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Subpart I—SANCTIONS
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Basis for imposition of sanctions. |
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Types of intermediate sanctions. |
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Amounts of civil money penalties. |
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Special rules for temporary management. |
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Termination of an MCO, PCCM or PCCM entity contract. |
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Notice of sanction and pre-termination hearing. |
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Disenrollment during termination hearing process. |
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Sanction by CMS: Special rules for MCOs. |
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Subpart J—CONDITIONS FOR FEDERAL FINANCIAL PARTICIPATION (FFP)
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Expenditures for enrollment broker services. |
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Costs under risk and nonrisk contracts. |
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Expenditures for the beneficiary support system for enrollees using LTSS. |
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Subpart K—PARITY IN MENTAL HEALTH AND SUBSTANCE USE DISORDER BENEFITS
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Parity requirements for aggregate lifetime and annual dollar limits. |
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Parity requirements for financial requirements and treatment limitations. |
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Availability of information. |
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