e-CFR data is current as of July 6, 2020
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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