e-CFR banner

Home
gpo.gov
govinfo.gov

e-CFR Navigation Aids

Browse

Simple Search

Advanced Search

 — Boolean

 — Proximity

 

Search History

Search Tips

Corrections

Latest Updates

User Info

FAQs

Agency List

Incorporation By Reference

eCFR logo

Related Resources

 

Electronic Code of Federal Regulations

e-CFR data is current as of November 13, 2019

Title 42Chapter IVSubchapter CPart 438


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

rule

Subpart A—GENERAL PROVISIONS

§438.1
Basis and scope.
§438.2
Definitions.
§438.3
Standard contract requirements.
§438.4
Actuarial soundness.
§438.5
Rate development standards.
§438.6
Special contract provisions related to payment.
§438.7
Rate certification submission.
§438.8
Medical loss ratio (MLR) standards.
§438.9
Provisions that apply to non-emergency medical transportation PAHPs.
§438.10
Information requirements.
§438.12
Provider discrimination prohibited.
§438.14
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).
rule

Subpart B—STATE RESPONSIBILITIES

§438.50
State Plan requirements.
§438.52
Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities.
§438.54
Managed care enrollment.
§438.56
Disenrollment: Requirements and limitations.
§438.58
Conflict of interest safeguards.
§438.60
Prohibition of additional payments for services covered under MCO, PIHP or PAHP contracts.
§438.62
Continued services to enrollees.
§438.66
State monitoring requirements.
§438.68
Network adequacy standards.
§438.70
Stakeholder engagement when LTSS is delivered through a managed care program.
§438.71
Beneficiary support system.
§438.74
State oversight of the minimum MLR requirement.
rule

Subpart C—ENROLLEE RIGHTS AND PROTECTIONS

§438.100
Enrollee rights.
§438.102
Provider-enrollee communications.
§438.104
Marketing activities.
§438.106
Liability for payment.
§438.108
Cost sharing.
§438.110
Member advisory committee.
§438.114
Emergency and poststabilization services.
§438.116
Solvency standards.
rule

Subpart D—MCO, PIHP AND PAHP STANDARDS

§438.206
Availability of services.
§438.207
Assurances of adequate capacity and services.
§438.208
Coordination and continuity of care.
§438.210
Coverage and authorization of services.
§438.214
Provider selection.
§438.224
Confidentiality.
§438.228
Grievance and appeal systems.
§438.230
Subcontractual relationships and delegation.
§438.236
Practice guidelines.
§438.242
Health information systems.
rule

Subpart E—QUALITY MEASUREMENT AND IMPROVEMENT; EXTERNAL QUALITY REVIEW

§438.310
Basis, scope, and applicability.
§438.320
Definitions.
§438.330
Quality assessment and performance improvement program.
§438.332
State review of the accreditation status of MCOs, PIHPs, and PAHPs.
§438.334
Medicaid managed care quality rating system.
§438.340
Managed care State quality strategy.
§438.350
External quality review.
§438.352
External quality review protocols.
§438.354
Qualifications of external quality review organizations.
§438.356
State contract options for external quality review.
§438.358
Activities related to external quality review.
§438.360
Nonduplication of mandatory activities with Medicare or accreditation review.
§438.362
Exemption from external quality review.
§438.364
External quality review results.
§438.370
Federal financial participation (FFP).
rule

Subpart F—GRIEVANCE AND APPEAL SYSTEM

§438.400
Statutory basis, definitions, and applicability.
§438.402
General requirements.
§438.404
Timely and adequate notice of adverse benefit determination.
§438.406
Handling of grievances and appeals.
§438.408
Resolution and notification: Grievances and appeals.
§438.410
Expedited resolution of appeals.
§438.414
Information about the grievance and appeal system to providers and subcontractors.
§438.416
Recordkeeping requirements.
§438.420
Continuation of benefits while the MCO, PIHP, or PAHP appeal and the State fair hearing are pending.
§438.424
Effectuation of reversed appeal resolutions.
rule

Subpart G—[RESERVED]

rule

Subpart H—ADDITIONAL PROGRAM INTEGRITY SAFEGUARDS

§438.600
Statutory basis, basic rule, and applicability.
§438.602
State responsibilities.
§438.604
Data, information, and documentation that must be submitted.
§438.606
Source, content, and timing of certification.
§438.608
Program integrity requirements under the contract.
§438.610
Prohibited affiliations.
rule

Subpart I—SANCTIONS

§438.700
Basis for imposition of sanctions.
§438.702
Types of intermediate sanctions.
§438.704
Amounts of civil money penalties.
§438.706
Special rules for temporary management.
§438.708
Termination of an MCO, PCCM or PCCM entity contract.
§438.710
Notice of sanction and pre-termination hearing.
§438.722
Disenrollment during termination hearing process.
§438.724
Notice to CMS.
§438.726
State plan requirement.
§438.730
Sanction by CMS: Special rules for MCOs.
rule

Subpart J—CONDITIONS FOR FEDERAL FINANCIAL PARTICIPATION (FFP)

§438.802
Basic requirements.
§438.806
Prior approval.
§438.808
Exclusion of entities.
§438.810
Expenditures for enrollment broker services.
§438.812
Costs under risk and nonrisk contracts.
§438.816
Expenditures for the beneficiary support system for enrollees using LTSS.
§438.818
Enrollee encounter data.
rule

Subpart K—PARITY IN MENTAL HEALTH AND SUBSTANCE USE DISORDER BENEFITS

§438.900
Meaning of terms.
§438.905
Parity requirements for aggregate lifetime and annual dollar limits.
§438.910
Parity requirements for financial requirements and treatment limitations.
§438.915
Availability of information.
§438.920
Applicability.
§438.930
Compliance dates.

Need assistance?