|
Home Page > Executive Branch > Code of Federal Regulations > Electronic Code of Federal Regulations
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 C--MEDICAL ASSISTANCE PROGRAMS
PART 438--MANAGED CARE
Subpart A--GENERAL PROVISIONS
|
| Provisions that apply to PIHPs and PAHPs. |
|
|
| Information requirements. |
|
|
| Provider discrimination prohibited. |
|
Subpart B--STATE RESPONSIBILITIES
|
| Choice of MCOs, PIHPs, PAHPs, and PCCMs. |
|
|
| Disenrollment: Requirements and limitations. |
|
|
| Conflict of interest safeguards. |
|
|
| Limit on payment to other providers. |
|
Subpart C--ENROLLEE RIGHTS AND PROTECTIONS
|
| Provider-enrollee communications. |
|
|
| Emergency and poststabilization services. |
|
Subpart D--QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT
|
| Elements of State quality strategies. |
|
|
| Availability of services. |
|
|
| Assurances of adequate capacity and services. |
|
|
| Coordination and continuity of care. |
|
|
| Coverage and authorization of services. |
|
|
| Enrollment and disenrollment. |
|
|
| Subcontractual relationships and delegation. |
|
|
| Quality assessment and performance improvement program. |
|
|
| Health information systems. |
|
Subpart E--EXTERNAL QUALITY REVIEW
|
| Basis, scope, and applicability. |
|
|
| External quality review protocols. |
|
|
| Qualifications of external quality review organizations. |
|
|
| Activities related to external quality review. |
|
|
| Nonduplication of mandatory activities. |
|
|
| Exemption from external quality review. |
|
|
| External quality review results. |
|
|
| Federal financial participation. |
|
Subpart F--GRIEVANCE SYSTEM
|
| Statutory basis and definitions. |
|
|
| Handling of grievances and appeals. |
|
|
| Resolution and notification: Grievances and appeals. |
|
|
| Expedited resolution of appeals. |
|
|
| Information about the grievance system to providers and subcontractors. |
|
|
| Recordkeeping and reporting requirements. |
|
|
| Continuation of benefits while the MCO or PIHP appeal and the State fair hearing are pending. |
|
|
| Effectuation of reversed appeal resolutions. |
|
Subpart G--[RESERVED]
Subpart H--CERTIFICATIONS AND PROGRAM INTEGRITY
|
| Data that must be certified. |
|
|
| Source, content, and timing of certification. |
|
|
| Program integrity requirements. |
|
|
| Prohibited affiliations with individuals debarred by Federal agencies. |
|
Subpart I--SANCTIONS
|
| Basis for imposition of sanctions. |
|
|
| Types of intermediate sanctions. |
|
|
| Amounts of civil money penalties. |
|
|
| Special rules for temporary management. |
|
|
| Termination of an MCO or PCCM contract. |
|
|
| Due process: Notice of sanction and pre-termination hearing. |
|
|
| Disenrollment during termination hearing process. |
|
|
| Sanction by CMS: Special rules for MCOs |
|
Subpart J--CONDITIONS FOR FEDERAL FINANCIAL PARTICIPATION
|
| Expenditures for enrollment broker services. |
|
|
| Costs under risk and nonrisk contracts. |
|
|
