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