42 CFR Part 438
PART 438—MANAGED CARE
- PART 438—MANAGED CARE
- Chapter IV—Centers for Medicare & Medicaid Services, Department of Health and Human Services › Subchapter C—Medical Assistance Programs
- Subpart A—General Provisions
- § 438.1 Basis and scope.
- § 438.2 Definitions.
- § 438.3 Standard contract requirements.
- § 438.4 Actuarial soundness.
- § 438.5 Rate development standards.
- § 438.6 Special contract provisions related to payment.
- § 438.7 Rate certification submission.
- § 438.8 Medical loss ratio (MLR) standards.
- § 438.9 Provisions that apply to non-emergency medical transportation PAHPs.
- § 438.10 Information requirements.
- § 438.12 Provider discrimination prohibited.
- § 438.14 Requirements that apply to MCO, PIHP, PAHP, PCCM, and PCCM entity contracts involving Indians, Indian health care providers (IHCPs), and Indian managed care entities (IMCEs).
- § 438.16 In lieu of services and settings (ILOS) requirements.
- Subpart B—State Responsibilities
- § 438.50 State Plan requirements.
- § 438.52 Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities.
- § 438.54 Managed care enrollment.
- § 438.56 Disenrollment: Requirements and limitations.
- § 438.58 Conflict of interest safeguards.
- § 438.60 Prohibition of additional payments for services covered under MCO, PIHP or PAHP contracts.
- § 438.62 Continued services to enrollees.
- § 438.66 State monitoring requirements.
- § 438.68 Network adequacy standards.
- § 438.70 Stakeholder engagement when LTSS is delivered through a managed care program.
- § 438.71 Beneficiary support system.
- § 438.72 Additional requirements for long-term services and supports.
- § 438.74 State oversight of the minimum MLR requirement.
- Subpart C—Enrollee Rights and Protections
- § 438.100 Enrollee rights.
- § 438.102 Provider-enrollee communications.
- § 438.104 Marketing activities.
- § 438.106 Liability for payment.
- § 438.108 Cost sharing.
- § 438.110 Member advisory committee.
- § 438.114 Emergency and poststabilization services.
- § 438.116 Solvency standards.
- Subpart D—MCO, PIHP and PAHP Standards
- § 438.206 Availability of services.
- § 438.207 Assurances of adequate capacity and services.
- § 438.208 Coordination and continuity of care.
- § 438.210 Coverage and authorization of services.
- § 438.214 Provider selection.
- § 438.224 Confidentiality.
- § 438.228 Grievance and appeal systems.
- § 438.230 Subcontractual relationships and delegation.
- § 438.236 Practice guidelines.
- § 438.242 Health information systems.
- Subpart E—Quality Measurement and Improvement; External Quality Review
- § 438.310 Basis, scope, and applicability.
- § 438.320 Definitions.
- § 438.330 Quality assessment and performance improvement program.
- § 438.332 State review of the accreditation status of MCOs, PIHPs, and PAHPs.
- § 438.334 [Reserved]
- § 438.340 Managed care State quality strategy.
- § 438.350 External quality review.
- § 438.352 External quality review protocols.
- § 438.354 Qualifications of external quality review organizations.
- § 438.356 State contract options for external quality review.
- § 438.358 Activities related to external quality review.
- § 438.360 Nonduplication of mandatory activities with Medicare or accreditation review.
- § 438.362 Exemption from external quality review.
- § 438.364 External quality review results.
- § 438.370 Federal financial participation (FFP).
- Subpart F—Grievance and Appeal System
- § 438.400 Statutory basis, definitions, and applicability.
- § 438.402 General requirements.
- § 438.404 Timely and adequate notice of adverse benefit determination.
- § 438.406 Handling of grievances and appeals.
- § 438.408 Resolution and notification: Grievances and appeals.
- § 438.410 Expedited resolution of appeals.
- § 438.414 Information about the grievance and appeal system to providers and subcontractors.
- § 438.416 Recordkeeping requirements.
- § 438.420 Continuation of benefits while the MCO, PIHP, or PAHP appeal and the State fair hearing are pending.
- § 438.424 Effectuation of reversed appeal resolutions.
- Subpart G—Medicaid Managed Care Quality Rating System
- § 438.500 Definitions.
- § 438.505 General rule and applicability.
- § 438.510 Mandatory QRS measure set for Medicaid managed care quality rating system.
- § 438.515 Medicaid managed care quality rating system methodology.
- § 438.520 website display.
- § 438.525 [Reserved]
- § 438.530 Annual technical resource manual.
- § 438.535 Annual reporting.
- Subpart H—Additional Program Integrity Safeguards
- § 438.600 Statutory basis, basic rule, and applicability.
- § 438.602 State responsibilities.
- § 438.604 Data, information, and documentation that must be submitted.
- § 438.606 Source, content, and timing of certification.
- § 438.608 Program integrity requirements under the contract.
- § 438.610 Prohibited affiliations.
- Subpart I—Sanctions
- § 438.700 Basis for imposition of sanctions.
- § 438.702 Types of intermediate sanctions.
- § 438.704 Amounts of civil money penalties.
- § 438.706 Special rules for temporary management.
- § 438.708 Termination of an MCO, PCCM or PCCM entity contract.
- § 438.710 Notice of sanction and pre-termination hearing.
- § 438.722 Disenrollment during termination hearing process.
- § 438.724 Notice to CMS.
- § 438.726 State plan requirement.
- § 438.730 Sanction by CMS: Special rules for MCOs.
- Subpart J—Conditions for Federal Financial Participation (FFP)
- § 438.802 Basic requirements.
- § 438.806 Prior approval.
- § 438.808 Exclusion of entities.
- § 438.810 Expenditures for enrollment broker services.
- § 438.812 Costs under risk and nonrisk contracts.
- § 438.816 Expenditures for the beneficiary support system for enrollees using LTSS.
- § 438.818 Enrollee encounter data.
- Subpart K—Parity in Mental Health and Substance Use Disorder Benefits
- § 438.900 Meaning of terms.
- § 438.905 Parity requirements for aggregate lifetime and annual dollar limits.
- § 438.910 Parity requirements for financial requirements and treatment limitations.
- § 438.915 Availability of information.
- § 438.920 Applicability.
- § 438.930 Compliance dates.
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