2004 CFR Title 42, Volume 2

Title 42--Public Health CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES PART 417--HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS
	417.1	Definitions.
	417.2	Basis and scope.
	417.101	Health benefits plan: Basic health services.
	417.102	Health benefits plan: Supplemental health services.
	417.103	Providers of basic and supplemental health services.
	417.104	Payment for basic health services.
	417.105	Payment for supplemental health services.
	417.106	Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services.
	417.120	Fiscally sound operation and assumption of financial risk.
	417.122	Protection of enrollees.
	417.124	Administration and management.
	417.126	Recordkeeping and reporting requirements.
	417.140	Scope.
	417.142	Requirements for qualification.
	417.143	Application requirements.
	417.144	Evaluation and determination procedures.
	417.150	Definitions.
	417.151	Applicability.
	417.153	Offer of HMO alternative.
	417.155	How the HMO option must be included in the health benefits plan.
	417.156	When the HMO must be offered to employees.
	417.157	Contributions for the HMO alternative.
	417.158	Payroll deductions.
	417.159	Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway Labor Act.
	417.160	Applicability.
	417.161	Compliance with assurances.
	417.162	Reporting requirements.
	417.163	Enforcement procedures.
	417.164	Effect of revocation of qualification on inclusion in employee's health benefit plans.
	417.165	Reapplication for qualification.
	417.166	Waiver of assurances.
	417.400	Basis and scope.
	417.401	Definitions.
	417.402	Effective date of initial regulations.
	417.404	General requirements.
	417.406	Application and determination.
	417.407	Requirements for a Competitive Medical Plan (CMP).
	417.408	Contract application process.
	417.410	Qualifying conditions: General rules.
	417.412	Qualifying condition: Administration and management.
	417.413	Qualifying condition: Operating experience and enrollment.
	417.414	Qualifying condition: Range of services.
	417.416	Qualifying condition: Furnishing of services.
	417.418	Qualifying condition: Quality assurance program.
	417.420	Basic rules on enrollment and entitlement.
	417.422	Eligibility to enroll in an HMO or CMP.
	417.423	Special rules: ESRD and hospice patients.
	417.424	Denial of enrollment.
	417.426	Open enrollment requirements.
	417.428	Marketing activities.
	417.430	Application procedures.
	417.432	Conversion of enrollment.
	417.434	Reenrollment.
	417.436	Rules for enrollees.
	417.440	Entitlement to health care services from an HMO or CMP.
	417.442	Risk HMO's and CMP's: Conditions for provision of additional benefits.
	417.444	Special rules for certain enrollees of risk HMOs and CMPs.
	417.448	Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.
	417.450	Effective date of coverage.
	417.452	Liability of Medicare enrollees.
	417.454	Charges to Medicare enrollees.
	417.456	Refunds to Medicare enrollees.
	417.458	Recoupment of uncollected deductible and coinsurance amounts.
	417.460	Disenrollment of beneficiaries by an HMO or CMP.
	417.461	Disenrollment by the enrollee.
	417.464	End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract.
	417.470	Basis and scope.
	417.472	Basic contract requirements.
	417.474	Effective date and term of contract.
	417.476	Waived conditions.
	417.478	Requirements of other laws and regulations.
	417.479	Requirements for physician incentive plans.
	417.480	Maintenance of records: Cost HMOs and CMPs.
	417.481	Maintenance of records: Risk HMOs and CMPs.
	417.482	Access to facilities and records.
	417.484	Requirement applicable to related entities.
	417.486	Disclosure of information and confidentiality.
	417.488	Notice of termination and of available alternatives: Risk contract.
	417.490	Renewal of contract.
	417.492	Nonrenewal of contract.
	417.494	Modification or termination of contract.
	417.500	Sanctions against HMOs and CMPs.
	417.520	Effect on HMO and CMP contracts.
	417.524	Payment to HMOs or CMPs: General.
	417.526	Payment for covered services.
	417.528	Payment when Medicare is not primary payer.
	417.530	Basis and scope.
	417.531	Hospice care services.
	417.532	General considerations.
	417.533	Part B carrier responsibilities.
	417.534	Allowable costs.
	417.536	Cost payment principles.
	417.538	Enrollment and marketing costs.
	417.540	Enrollment costs.
	417.542	Reinsurance costs.
	417.544	Physicians' services furnished directly by the HMO or CMP.
	417.546	Physicians' services and other Part B supplier services furnished under arrangements.
	417.548	Provider services through arrangements.
	417.550	Special Medicare program requirements.
	417.552	Cost apportionment: General provisions.
	417.554	Apportionment: Provider services furnished directly by the HMO or CMP.
	417.556	Apportionment: Provider services furnished by the HMO or CMP through arrangements with others.
	417.558	Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility.
	417.560	Apportionment: Part B physician and supplier services.
	417.564	Apportionment and allocation of administrative and general costs.
	417.566	Other methods of allocation and apportionment.
	417.568	Adequate financial records, statistical data, and cost finding.
	417.570	Interim per capita payments.
	417.572	Budget and enrollment forecast and interim reports.
	417.574	Interim settlement.
	417.576	Final settlement.
	417.580	Basis and scope.
	417.582	Definitions.
	417.584	Payment to HMOs or CMPs with risk contracts.
	417.585	Special rules: Hospice care.
	417.588	Computation of adjusted average per capita cost (AAPCC).
	417.590	Computation of the average of the per capita rates of payment.
	417.592	Additional benefits requirement.
	417.594	Computation of adjusted community rate (ACR).
	417.596	Establishment of a benefit stabilization fund.
	417.597	Withdrawal from a benefit stabilization fund.
	417.598	Annual enrollment reconciliation.
	417.600	Basis and scope.
	417.602	Definitions.
	417.604	General provisions.
	417.605	Immediate QIO review of a determination of noncoverage of inpatient hospital care.
	417.606	Organization determinations.
	417.608	Notice of adverse organization determination.
	417.609	Expediting certain organization determinations.
	417.610	Parties to the organization determination.
	417.612	Effect of organization determination.
	417.614	Right to reconsideration.
	417.616	Request for reconsideration.
	417.617	Expediting certain reconsiderations.
	417.618	Opportunity to submit evidence.
	417.620	Responsibility for reconsiderations; time limits.
	417.622	Reconsidered determination.
	417.624	Notice of reconsidered determination.
	417.626	Effect of reconsidered determination.
	417.630	Right to a hearing.
	417.632	Request for hearing.
	417.634	Departmental Appeals Board (DAB) review.
	417.636	Court review.
	417.638	Reopening determinations and decisions.
	417.640	Determinations subject to appeal.
	417.642	Administrative actions that are not initial determinations.
	417.644	Notice of initial determination.
	417.646	Effect of initial determination.
	417.648	Reconsideration: Applicability.
	417.650	Request for reconsideration.
	417.652	Opportunity to submit evidence.
	417.654	Reconsidered determination.
	417.656	Notice of reconsidered determination.
	417.658	Effect of reconsidered determination.
	417.660	Right to a hearing.
	417.662	Request for hearing.
	417.664	Postponement of effective date of initial determination.
	417.666	Designation of hearing officer.
	417.668	Disqualification of hearing officer.
	417.670	Time and place of hearing.
	417.672	Appointment of representatives.
	417.674	Authority of representatives.
	417.676	Conduct of hearing.
	417.678	Evidence.
	417.680	Witnesses.
	417.682	Discovery.
	417.684	Prehearing.
	417.686	Record of hearing.
	417.688	Authority of hearing officer.
	417.690	Notice and effect of hearing decision.
	417.692	Reopening of initial or reconsidered determination or decision of a hearing officer.
	417.694	Effect of revised determination.
	417.800	Payment to HCPPs: Definitions and basic rules.
	417.801	Agreements between CMS and health care prepayment plans.
	417.802	Allowable costs.
	417.804	Cost apportionment.
	417.806	Financial records, statistical data, and cost finding.
	417.808	Interim per capita payments.
	417.810	Final settlement.
	417.830	Scope of regulations on beneficiary appeals.
	417.832	Applicability of requirements and procedures.
	417.834	Responsibility for establishing administrative review procedures.
	417.836	Written description of administrative review procedures.
	417.838	Organization determinations.
	417.840	Administrative review procedures.
	417.910	Applicability.
	417.911	Definitions.
	417.920	Planning and initial development.
	417.930	Initial costs of operation.
	417.934	Reserve requirement.
	417.937	Loan and loan guarantee provisions.
	417.940	Civil action to enforce compliance with assurances.