42 CFR Part 417
PART 417—HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS
- PART 417—HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS
- Chapter IV—Centers for Medicare & Medicaid Services, Department of Health and Human Services › Subchapter B—Medicare Program
- Subpart A—General Provisions
- § 417.1 Definitions.
- § 417.2 Basis and scope.
- Subpart B—Qualified Health Maintenance Organizations: Services
- § 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.
- Subpart C—Qualified Health Maintenance Organizations: Organization and Operation
- § 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.
- Subpart D—Application for Federal Qualification
- § 417.140 Scope.
- § 417.142 Requirements for qualification.
- § 417.143 Application requirements.
- § 417.144 Evaluation and determination procedures.
- Subpart E—Inclusion of Qualified Health Maintenance Organizations in Employee Health Benefits Plans
- § 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.
- Subpart F—Continued Regulation of Federally Qualified Health Maintenance Organizations
- § 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.
- Subparts G-I [Reserved]
- Subpart J—Qualifying Conditions for Medicare Contracts
- § 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.
- Subpart K—Enrollment, Entitlement, and Disenrollment under Medicare Contract
- § 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.
- § 417.427 Extending MA and Part D program disclosure requirements to section 1876 cost contract plans.
- § 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.
- § 417.446 [Reserved]
- § 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.
- Subpart L—Medicare Contract Requirements
- § 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.
- § 417.496 Cost plan crosswalk.
- § 417.500 Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.
- Subpart M—Change of Ownership and Leasing of Facilities: Effect on Medicare Contract
- § 417.520 Effect on HMO and CMP contracts.
- Subpart N—Medicare Payment to HMOs and CMPs: General Rules
- § 417.524 Payment to HMOs or CMPs: General.
- § 417.526 Payment for covered services.
- § 417.528 Payment when Medicare is not primary payer.
- Subpart O—Medicare Payment: Cost Basis
- § 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.
- Subpart P—Medicare Payment: Risk Basis
- § 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.
- Subpart Q—Beneficiary Appeals
- § 417.600 Basis and scope.
- Subpart R—Medicare Contract Appeals
- § 417.640 Applicability.
- Subparts S-T [Reserved]
- Subpart U—Health Care Prepayment Plans
- § 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.
- Subpart V—Administration of Outstanding Loans and Loan Guarantees
- § 417.910 Applicability.
- § 417.911 Definitions.
- § 417.920 Planning and initial development.
- § 417.930 Initial costs of operation.
- § 417.931 [Reserved]
- § 417.934 Reserve requirement.
- § 417.937 Loan and loan guarantee provisions.
- § 417.940 Civil action to enforce compliance with assurances.
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