Title 42--Public Health

CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

PART 438--MANAGED CARE PROVISIONS

TEXT PDF438.1 Basis and scope.
TEXT PDF438.2 Definitions.
TEXT PDF438.6 Contract requirements.
TEXT PDF438.8 Provisions that apply to PHPs.
TEXT PDF438.10 Information requirements.
TEXT PDF438.12 Provider discrimination prohibited.
TEXT PDF438.50 State plan requirements.
TEXT PDF438.52 Choice of MCOs, PHPs, and PCCMs.
TEXT PDF438.56 Disenrollment: Requirements and limitations.
TEXT PDF438.58 Conflict of interest safeguards.
TEXT PDF438.60 Limit on payment to other providers.
TEXT PDF438.62 Continued services to recipients.
TEXT PDF438.66 Monitoring procedures.
TEXT PDF438.68 Education of MCOs, PHPs, and PCCMs and subcontracting providers.
TEXT PDF438.100 Enrollee rights.
TEXT PDF438.102 Provider-enrollee communications.
TEXT PDF438.104 Marketing activities.
TEXT PDF438.106 Liability for payment.
TEXT PDF438.108 Cost sharing.
TEXT PDF438.114 Emergency and post-stabilization services.
TEXT PDF438.116 Solvency standards.
TEXT PDF438.200 Scope.
TEXT PDF438.202 State responsibilities.
TEXT PDF438.204 Elements of State quality strategies.
TEXT PDF438.206 Availability of services.
TEXT PDF438.207 Assurances of adequate capacity and services.
TEXT PDF438.208 Coordination and continuity of care.
TEXT PDF438.210 Coverage and authorization of services.
TEXT PDF438.214 Provider selection.
TEXT PDF438.218 Enrollee information.
TEXT PDF438.224 Confidentiality and accuracy of enrollee records.
TEXT PDF438.226 Enrollment and disenrollment.
TEXT PDF438.228 Grievance systems.
TEXT PDF438.230 Subcontractual relationships and delegation.
TEXT PDF438.236 Practice guidelines.
TEXT PDF438.240 Quality assessment and performance improvement program.
TEXT PDF438.242 Health information systems.
TEXT PDF438.400 Statutory basis and definitions.
TEXT PDF438.402 General requirements.
TEXT PDF438.404 Notice of action.
TEXT PDF438.406 Handling of grievances and appeals.
TEXT PDF438.408 Resolution and notification: Grievances and appeals.
TEXT PDF438.410 Expedited resolution of grievances and appeals.
TEXT PDF438.414 Information about the grievance system.
TEXT PDF438.416 Record keeping and reporting requirements.
TEXT PDF438.420 Continuation of benefits while the MCO or PHP appeal and the State Fair Hearing are pending.
TEXT PDF438.424 Effectuation of reversed appeal resolutions.
TEXT PDF438.426 Monitoring of the grievance system.
TEXT PDF438.600 Statutory basis.
TEXT PDF438.602 Basic rule.
TEXT PDF438.604 Data that must be certified.
TEXT PDF438.606 Source, content, and timing of certification.
TEXT PDF438.608 Program integrity requirements.
TEXT PDF438.700 Basis for imposition of sanctions.
TEXT PDF438.702 Types of intermediate sanctions.
TEXT PDF438.704 Amounts of civil money penalties
TEXT PDF438.706 Special rules for temporary management.
TEXT PDF438.708 Termination of an MCO or PCCM contract.
TEXT PDF438.710 Due process: Notice of sanction and pre-termination hearing.
TEXT PDF438.722 Disenrollment during termination hearing process.
TEXT PDF438.724 Public notice of sanction.
TEXT PDF438.726 State plan requirement.
TEXT PDF438.730 Sanction by CMS: Special rules for MCOs with risk contracts.
TEXT PDF438.802 Basic requirements.
TEXT PDF438.806 Prior approval.
TEXT PDF438.808 Exclusion of entities.
TEXT PDF438.810 Expenditures for enrollment broker services.
TEXT PDF438.812 Costs under risk and nonrisk contracts.
TEXT PDF438.814 Limit on payments in excess of capitation rates.

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