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e-CFR Data is current as of February 4, 2010
TITLE 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B--MEDICARE PROGRAM
PART 417--HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS
Subpart A--GENERAL PROVISIONS
Subpart B--QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS: SERVICES
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| Health benefits plan: Basic health services. |
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| Health benefits plan: Supplemental health services. |
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| Providers of basic and supplemental health services. |
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| Payment for basic health services. |
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| Payment for supplemental health services. |
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| Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services. |
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Subpart C--QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS: ORGANIZATION AND OPERATION
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| Fiscally sound operation and assumption of financial risk. |
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| Administration and management. |
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| Recordkeeping and reporting requirements. |
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Subpart D--APPLICATION FOR FEDERAL QUALIFICATION
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| Requirements for qualification. |
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| Application requirements. |
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| Evaluation and determination procedures. |
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Subpart E--INCLUSION OF QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS IN EMPLOYEE HEALTH BENEFITS PLANS
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| Offer of HMO alternative. |
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| How the HMO option must be included in the health benefits plan. |
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| When the HMO must be offered to employees. |
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| Contributions for the HMO alternative. |
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| Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway Labor Act. |
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Subpart FREGULATION OF FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS
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| Compliance with assurances. |
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| Effect of revocation of qualification on inclusion in employee's health benefit plans. |
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| Reapplication for qualification. |
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Subparts G-I--[RESERVED]
Subpart J--QUALIFYING CONDITIONS FOR MEDICARE CONTRACTS
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| Effective date of initial regulations. |
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| Application and determination. |
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| Requirements for a Competitive Medical Plan (CMP). |
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| Contract application process. |
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| Qualifying conditions: General rules. |
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| Qualifying condition: Administration and management. |
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| Qualifying condition: Operating experience and enrollment. |
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| Qualifying condition: Range of services. |
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| Qualifying condition: Furnishing of services. |
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| Qualifying condition: Quality assurance program. |
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Subpart K--ENROLLMENT, ENTITLEMENT, AND DISENROLLMENT UNDER MEDICARE CONTRACT
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| Basic rules on enrollment and entitlement. |
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| Eligibility to enroll in an HMO or CMP. |
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| Special rules: ESRD and hospice patients. |
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| Open enrollment requirements. |
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| Conversion of enrollment. |
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| Entitlement to health care services from an HMO or CMP. |
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| Risk HMO's and CMP's: Conditions for provision of additional benefits. |
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| Special rules for certain enrollees of risk HMOs and CMPs. |
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| Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs. |
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| Effective date of coverage. |
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| Liability of Medicare enrollees. |
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| Charges to Medicare enrollees. |
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| Refunds to Medicare enrollees. |
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| Recoupment of uncollected deductible and coinsurance amounts. |
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| Disenrollment of beneficiaries by an HMO or CMP. |
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| Disenrollment by the enrollee. |
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| End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract. |
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Subpart L--MEDICARE CONTRACT REQUIREMENTS
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| Basic contract requirements. |
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| Effective date and term of contract. |
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| Requirements of other laws and regulations. |
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| Requirements for physician incentive plans. |
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| Maintenance of records: Cost HMOs and CMPs. |
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| Maintenance of records: Risk HMOs and CMPs. |
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| Access to facilities and records. |
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| Requirement applicable to related entities. |
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| Disclosure of information and confidentiality. |
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| Notice of termination and of available alternatives: Risk contract. |
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| Modification or termination of contract. |
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| Sanctions against HMOs and CMPs. |
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Subpart M--CHANGE OF OWNERSHIP AND LEASING OF FACILITIES: EFFECT ON MEDICARE CONTRACT
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| Effect on HMO and CMP contracts. |
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Subpart N--MEDICARE PAYMENT TO HMOS AND CMPS: GENERAL RULES
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| Payment to HMOs or CMPs: General. |
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| Payment for covered services. |
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| Payment when Medicare is not primary payer. |
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Subpart O--MEDICARE PAYMENT: COST BASIS
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| Part B carrier responsibilities. |
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| Enrollment and marketing costs. |
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| Physicians' services furnished directly by the HMO or CMP. |
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| Physicians' services and other Part B supplier services furnished under arrangements. |
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| Provider services through arrangements. |
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| Special Medicare program requirements. |
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| Cost apportionment: General provisions. |
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| Apportionment: Provider services furnished directly by the HMO or CMP. |
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| Apportionment: Provider services furnished by the HMO or CMP through arrangements with others. |
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| Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility. |
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| Apportionment: Part B physician and supplier services. |
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| Apportionment and allocation of administrative and general costs. |
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| Other methods of allocation and apportionment. |
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| Adequate financial records, statistical data, and cost finding. |
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| Interim per capita payments. |
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| Budget and enrollment forecast and interim reports. |
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Subpart P--MEDICARE PAYMENT: RISK BASIS
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| Payment to HMOs or CMPs with risk contracts. |
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| Special rules: Hospice care. |
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| Computation of adjusted average per capita cost (AAPCC). |
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| Computation of the average of the per capita rates of payment. |
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| Additional benefits requirement. |
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| Computation of adjusted community rate (ACR). |
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| Establishment of a benefit stabilization fund. |
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| Withdrawal from a benefit stabilization fund. |
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| Annual enrollment reconciliation. |
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Subpart Q--BENEFICIARY APPEALS
Subpart R--MEDICARE CONTRACT APPEALS
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| Determinations subject to appeal. |
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| Administrative actions that are not initial determinations. |
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| Notice of initial determination. |
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| Effect of initial determination. |
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| Reconsideration: Applicability. |
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| Request for reconsideration. |
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| Opportunity to submit evidence. |
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| Reconsidered determination. |
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| Notice of reconsidered determination. |
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| Effect of reconsidered determination. |
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| Postponement of effective date of initial determination. |
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| Designation of hearing officer. |
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| Disqualification of hearing officer. |
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| Time and place of hearing. |
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| Appointment of representatives. |
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| Authority of representatives. |
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| Authority of hearing officer. |
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| Notice and effect of hearing decision. |
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| Reopening of initial or reconsidered determination or decision of a hearing officer. |
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| Effect of revised determination. |
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Subparts S-T--[RESERVED]
Subpart U--HEALTH CARE PREPAYMENT PLANS
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| Payment to HCPPs: Definitions and basic rules. |
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| Agreements between CMS and health care prepayment plans. |
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| Financial records, statistical data, and cost finding. |
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| Interim per capita payments. |
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| Scope of regulations on beneficiary appeals. |
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| Applicability of requirements and procedures. |
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| Responsibility for establishing administrative review procedures. |
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| Written description of administrative review procedures. |
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| Organization determinations. |
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| Administrative review procedures. |
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Subpart V--ADMINISTRATION OF OUTSTANDING LOANS AND LOAN GUARANTEES
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| Planning and initial development. |
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| Initial costs of operation. |
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| Loan and loan guarantee provisions. |
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| Civil action to enforce compliance with assurances. |
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