e-CFR data is current as of February 25, 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 447—PAYMENTS FOR SERVICES
Subpart A—PAYMENTS: GENERAL PROVISIONS
|
Prohibition against reassignment of provider claims. |
|
|
Acceptance of State payment as payment in full. |
|
|
Provider restrictions: State plan requirements. |
|
|
Reduction of payments to providers. |
|
|
Direct payments to certain beneficiaries for physicians' or dentists' services. |
|
|
Prohibition on payment for provider-preventable conditions. |
|
|
Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments. |
|
|
Withholding Medicare payments to recover Medicaid overpayments. |
|
|
Payments for reserving beds in institutions. |
|
|
Timely claims payment by MCOs. |
|
Medicaid Premiums and Cost Sharing
|
Premiums and cost sharing: Basis and purpose. |
|
|
Cost sharing for services furnished in a hospital emergency department. |
|
|
Limitations on premiums and cost sharing. |
|
|
Beneficiary and public notice requirements. |
|
|
Options for claiming FFP payment for section 1920A presumptive eligibility medical assistance payments. |
|
|
FFP: Conditions related to pending investigations of credible allegations of fraud against the Medicaid program. |
|
Subpart B—PAYMENT METHODS: GENERAL PROVISIONS
|
Documentation of access to care and service payment rates. |
|
|
Medicaid provider participation and public process to inform access to care. |
|
|
Public notice of changes in Statewide methods and standards for setting payment rates. |
|
Subpart C—PAYMENT FOR INPATIENT HOSPITAL AND LONG-TERM CARE FACILITY SERVICES
Payment Rates
|
Procedures for CMS action on assurances and State plan amendments. |
|
Federal Financial Participation
|
FFP: Conditions relating to institutional reimbursement. |
|
Upper Limits
|
Upper limits based on customary charges. |
|
|
Inpatient services: Application of upper payment limits. |
|
Swing-Bed Hospitals
|
Hospital providers of NF services (swing-bed hospitals). |
|
Subpart D—[RESERVED]
Subpart E—PAYMENT ADJUSTMENTS FOR HOSPITALS THAT SERVE A DISPROPORTIONATE NUMBER OF LOW-INCOME PATIENTS
|
Medicaid disproportionate share hospital (DSH) allotment reductions. |
|
|
Hospital-specific disproportionate share hospital payment limit: Determination of individuals without health insurance or other third party coverage. |
|
|
Limitations on aggregate payments for disproportionate share hospitals for the period January 1, 1992 through September 30, 1992. |
|
|
Limitations on aggregate payments for disproportionate share hospitals beginning October 1, 1992. |
|
|
State disproportionate share hospital allotments. |
|
Subpart F—PAYMENT METHODS FOR OTHER INSTITUTIONAL AND NONINSTITUTIONAL SERVICES
|
Adherence to upper limits; FFP. |
|
Outpatient Hospital and Clinic Services
|
Outpatient hospital and clinic services: Application of upper payment limits. |
|
Other Inpatient and Outpatient Facilities
|
Other inpatient and outpatient facility services: Upper limits of payment. |
|
Prepaid Capitation Plans
|
Upper limits of payment: Nonrisk contract. |
|
Rural Health Clinic Services
|
Services furnished by rural health clinics. |
|
Subpart G—PAYMENTS FOR PRIMARY CARE SERVICES FURNISHED BY PHYSICIANS
|
Primary care services furnished by physicians with a specified specialty or subspecialty. |
|
|
Amount of required minimum payments. |
|
|
Availability of Federal financial participation (FFP). |
|
Subpart H—[RESERVED]
Subpart I—PAYMENT FOR DRUGS
|
Determination of average manufacturer price. |
|
|
Determination of best price. |
|
|
Authorized generic drugs. |
|
|
Identification of inhalation, infusion, instilled, implanted, or injectable drugs (5i drugs). |
|
|
Exclusion from best price of certain sales at a nominal price. |
|
|
Medicaid drug rebates (MDR). |
|
|
Requirements for manufacturers. |
|
|
Drugs: Aggregate upper limits of payment. |
|
|
Upper limits for multiple source drugs. |
|
|
Upper limits for drugs furnished as part of services. |
|
|
State plan requirements, findings, and assurances. |
|
|
Federal Financial Participation (FFP): Conditions relating to physician-administered drugs. |
|
|
Optional coverage of investigational drugs and other drugs not subject to rebate. |
|
|