| 42:4.0.1.1.8.1 | SUBPART A
| Subpart A - General Provisions | |
| 42:4.0.1.1.8.1.100.1 | SECTION 438.1
| 438.1 Basis and scope. | |
| 42:4.0.1.1.8.1.100.2 | SECTION 438.2
| 438.2 Definitions. | |
| 42:4.0.1.1.8.1.100.3 | SECTION 438.3
| 438.3 Standard contract requirements. | |
| 42:4.0.1.1.8.1.100.4 | SECTION 438.4
| 438.4 Actuarial soundness. | |
| 42:4.0.1.1.8.1.100.5 | SECTION 438.5
| 438.5 Rate development standards. | |
| 42:4.0.1.1.8.1.100.6 | SECTION 438.6
| 438.6 Special contract provisions related to payment. | |
| 42:4.0.1.1.8.1.100.7 | SECTION 438.7
| 438.7 Rate certification submission. | |
| 42:4.0.1.1.8.1.100.8 | SECTION 438.8
| 438.8 Medical loss ratio (MLR) standards. | |
| 42:4.0.1.1.8.1.100.9 | SECTION 438.9
| 438.9 Provisions that apply to non-emergency medical transportation PAHPs. | |
| 42:4.0.1.1.8.1.100.10 | SECTION 438.10
| 438.10 Information requirements. | |
| 42:4.0.1.1.8.1.100.11 | SECTION 438.12
| 438.12 Provider discrimination prohibited. | |
| 42:4.0.1.1.8.1.100.12 | SECTION 438.14
| 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). | |
| 42:4.0.1.1.8.2 | SUBPART B
| Subpart B - State Responsibilities | |
| 42:4.0.1.1.8.2.100.1 | SECTION 438.50
| 438.50 State Plan requirements. | |
| 42:4.0.1.1.8.2.100.2 | SECTION 438.52
| 438.52 Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities. | |
| 42:4.0.1.1.8.2.100.3 | SECTION 438.54
| 438.54 Managed care enrollment. | |
| 42:4.0.1.1.8.2.100.4 | SECTION 438.56
| 438.56 Disenrollment: Requirements and limitations. | |
| 42:4.0.1.1.8.2.100.5 | SECTION 438.58
| 438.58 Conflict of interest safeguards. | |
| 42:4.0.1.1.8.2.100.6 | SECTION 438.60
| 438.60 Prohibition of additional payments for services covered under MCO, PIHP or PAHP contracts. | |
| 42:4.0.1.1.8.2.100.7 | SECTION 438.62
| 438.62 Continued services to enrollees. | |
| 42:4.0.1.1.8.2.100.8 | SECTION 438.66
| 438.66 State monitoring requirements. | |
| 42:4.0.1.1.8.2.100.9 | SECTION 438.68
| 438.68 Network adequacy standards. | |
| 42:4.0.1.1.8.2.100.10 | SECTION 438.70
| 438.70 Stakeholder engagement when LTSS is delivered through a managed care program. | |
| 42:4.0.1.1.8.2.100.11 | SECTION 438.71
| 438.71 Beneficiary support system. | |
| 42:4.0.1.1.8.2.100.12 | SECTION 438.74
| 438.74 State oversight of the minimum MLR requirement. | |
| 42:4.0.1.1.8.3 | SUBPART C
| Subpart C - Enrollee Rights and Protections | |
| 42:4.0.1.1.8.3.100.1 | SECTION 438.100
| 438.100 Enrollee rights. | |
| 42:4.0.1.1.8.3.100.2 | SECTION 438.102
| 438.102 Provider-enrollee communications. | |
| 42:4.0.1.1.8.3.100.3 | SECTION 438.104
| 438.104 Marketing activities. | |
| 42:4.0.1.1.8.3.100.4 | SECTION 438.106
| 438.106 Liability for payment. | |
| 42:4.0.1.1.8.3.100.5 | SECTION 438.108
| 438.108 Cost sharing. | |
| 42:4.0.1.1.8.3.100.6 | SECTION 438.110
| 438.110 Member advisory committee. | |
| 42:4.0.1.1.8.3.100.7 | SECTION 438.114
| 438.114 Emergency and poststabilization services. | |
| 42:4.0.1.1.8.3.100.8 | SECTION 438.116
| 438.116 Solvency standards. | |
| 42:4.0.1.1.8.4 | SUBPART D
| Subpart D - MCO, PIHP and PAHP Standards | |
| 42:4.0.1.1.8.4.100.1 | SECTION 438.206
| 438.206 Availability of services. | |
| 42:4.0.1.1.8.4.100.2 | SECTION 438.207
| 438.207 Assurances of adequate capacity and services. | |
| 42:4.0.1.1.8.4.100.3 | SECTION 438.208
| 438.208 Coordination and continuity of care. | |
| 42:4.0.1.1.8.4.100.4 | SECTION 438.210
| 438.210 Coverage and authorization of services. | |
| 42:4.0.1.1.8.4.100.5 | SECTION 438.214
| 438.214 Provider selection. | |
| 42:4.0.1.1.8.4.100.6 | SECTION 438.224
| 438.224 Confidentiality. | |
| 42:4.0.1.1.8.4.100.7 | SECTION 438.228
| 438.228 Grievance and appeal systems. | |
| 42:4.0.1.1.8.4.100.8 | SECTION 438.230
| 438.230 Subcontractual relationships and delegation. | |
| 42:4.0.1.1.8.4.100.9 | SECTION 438.236
| 438.236 Practice guidelines. | |
| 42:4.0.1.1.8.4.100.10 | SECTION 438.242
| 438.242 Health information systems. | |
| 42:4.0.1.1.8.5 | SUBPART E
| Subpart E - Quality Measurement and Improvement; External Quality Review | |
| 42:4.0.1.1.8.5.100.1 | SECTION 438.310
| 438.310 Basis, scope, and applicability. | |
| 42:4.0.1.1.8.5.100.2 | SECTION 438.320
| 438.320 Definitions. | |
| 42:4.0.1.1.8.5.100.3 | SECTION 438.330
| 438.330 Quality assessment and performance improvement program. | |
| 42:4.0.1.1.8.5.100.4 | SECTION 438.332
| 438.332 State review of the accreditation status of MCOs, PIHPs, and PAHPs. | |
| 42:4.0.1.1.8.5.100.5 | SECTION 438.334
| 438.334 Medicaid managed care quality rating system. | |
| 42:4.0.1.1.8.5.100.6 | SECTION 438.340
| 438.340 Managed care State quality strategy. | |
| 42:4.0.1.1.8.5.100.7 | SECTION 438.350
| 438.350 External quality review. | |
| 42:4.0.1.1.8.5.100.8 | SECTION 438.352
| 438.352 External quality review protocols. | |
| 42:4.0.1.1.8.5.100.9 | SECTION 438.354
| 438.354 Qualifications of external quality review organizations. | |
| 42:4.0.1.1.8.5.100.10 | SECTION 438.356
| 438.356 State contract options for external quality review. | |
| 42:4.0.1.1.8.5.100.11 | SECTION 438.358
| 438.358 Activities related to external quality review. | |
| 42:4.0.1.1.8.5.100.12 | SECTION 438.360
| 438.360 Nonduplication of mandatory activities with Medicare or accreditation review. | |
| 42:4.0.1.1.8.5.100.13 | SECTION 438.362
| 438.362 Exemption from external quality review. | |
| 42:4.0.1.1.8.5.100.14 | SECTION 438.364
| 438.364 External quality review results. | |
| 42:4.0.1.1.8.5.100.15 | SECTION 438.370
| 438.370 Federal financial participation (FFP). | |
| 42:4.0.1.1.8.6 | SUBPART F
| Subpart F - Grievance and Appeal System | |
| 42:4.0.1.1.8.6.100.1 | SECTION 438.400
| 438.400 Statutory basis, definitions, and applicability. | |
| 42:4.0.1.1.8.6.100.2 | SECTION 438.402
| 438.402 General requirements. | |
| 42:4.0.1.1.8.6.100.3 | SECTION 438.404
| 438.404 Timely and adequate notice of adverse benefit determination. | |
| 42:4.0.1.1.8.6.100.4 | SECTION 438.406
| 438.406 Handling of grievances and appeals. | |
| 42:4.0.1.1.8.6.100.5 | SECTION 438.408
| 438.408 Resolution and notification: Grievances and appeals. | |
| 42:4.0.1.1.8.6.100.6 | SECTION 438.410
| 438.410 Expedited resolution of appeals. | |
| 42:4.0.1.1.8.6.100.7 | SECTION 438.414
| 438.414 Information about the grievance and appeal system to providers and subcontractors. | |
| 42:4.0.1.1.8.6.100.8 | SECTION 438.416
| 438.416 Recordkeeping requirements. | |
| 42:4.0.1.1.8.6.100.9 | SECTION 438.420
| 438.420 Continuation of benefits while the MCO, PIHP, or PAHP appeal and the State fair hearing are pending. | |
| 42:4.0.1.1.8.6.100.10 | SECTION 438.424
| 438.424 Effectuation of reversed appeal resolutions. | |
| 42:4.0.1.1.8.7 | SUBPART G
| Subpart G [Reserved] | |
| 42:4.0.1.1.8.8 | SUBPART H
| Subpart H - Additional Program Integrity Safeguards | |
| 42:4.0.1.1.8.8.100.1 | SECTION 438.600
| 438.600 Statutory basis, basic rule, and applicability. | |
| 42:4.0.1.1.8.8.100.2 | SECTION 438.602
| 438.602 State responsibilities. | |
| 42:4.0.1.1.8.8.100.3 | SECTION 438.604
| 438.604 Data, information, and documentation that must be submitted. | |
| 42:4.0.1.1.8.8.100.4 | SECTION 438.606
| 438.606 Source, content, and timing of certification. | |
| 42:4.0.1.1.8.8.100.5 | SECTION 438.608
| 438.608 Program integrity requirements under the contract. | |
| 42:4.0.1.1.8.8.100.6 | SECTION 438.610
| 438.610 Prohibited affiliations. | |
| 42:4.0.1.1.8.9 | SUBPART I
| Subpart I - Sanctions | |
| 42:4.0.1.1.8.9.100.1 | SECTION 438.700
| 438.700 Basis for imposition of sanctions. | |
| 42:4.0.1.1.8.9.100.2 | SECTION 438.702
| 438.702 Types of intermediate sanctions. | |
| 42:4.0.1.1.8.9.100.3 | SECTION 438.704
| 438.704 Amounts of civil money penalties. | |
| 42:4.0.1.1.8.9.100.4 | SECTION 438.706
| 438.706 Special rules for temporary management. | |
| 42:4.0.1.1.8.9.100.5 | SECTION 438.708
| 438.708 Termination of an MCO, PCCM or PCCM entity contract. | |
| 42:4.0.1.1.8.9.100.6 | SECTION 438.710
| 438.710 Notice of sanction and pre-termination hearing. | |
| 42:4.0.1.1.8.9.100.7 | SECTION 438.722
| 438.722 Disenrollment during termination hearing process. | |
| 42:4.0.1.1.8.9.100.8 | SECTION 438.724
| 438.724 Notice to CMS. | |
| 42:4.0.1.1.8.9.100.9 | SECTION 438.726
| 438.726 State plan requirement. | |
| 42:4.0.1.1.8.9.100.10 | SECTION 438.730
| 438.730 Sanction by CMS: Special rules for MCOs. | |
| 42:4.0.1.1.8.10 | SUBPART J
| Subpart J - Conditions for Federal Financial Participation (FFP) | |
| 42:4.0.1.1.8.10.100.1 | SECTION 438.802
| 438.802 Basic requirements. | |
| 42:4.0.1.1.8.10.100.2 | SECTION 438.806
| 438.806 Prior approval. | |
| 42:4.0.1.1.8.10.100.3 | SECTION 438.808
| 438.808 Exclusion of entities. | |
| 42:4.0.1.1.8.10.100.4 | SECTION 438.810
| 438.810 Expenditures for enrollment broker services. | |
| 42:4.0.1.1.8.10.100.5 | SECTION 438.812
| 438.812 Costs under risk and nonrisk contracts. | |
| 42:4.0.1.1.8.10.100.6 | SECTION 438.816
| 438.816 Expenditures for the beneficiary support system for enrollees using LTSS. | |
| 42:4.0.1.1.8.10.100.7 | SECTION 438.818
| 438.818 Enrollee encounter data. | |
| 42:4.0.1.1.8.11 | SUBPART K
| Subpart K - Parity in Mental Health and Substance Use Disorder Benefits | |
| 42:4.0.1.1.8.11.100.1 | SECTION 438.900
| 438.900 Meaning of terms. | |
| 42:4.0.1.1.8.11.100.2 | SECTION 438.905
| 438.905 Parity requirements for aggregate lifetime and annual dollar limits. | |
| 42:4.0.1.1.8.11.100.3 | SECTION 438.910
| 438.910 Parity requirements for financial requirements and treatment limitations. | |
| 42:4.0.1.1.8.11.100.4 | SECTION 438.915
| 438.915 Availability of information. | |
| 42:4.0.1.1.8.11.100.5 | SECTION 438.920
| 438.920 Applicability. | |
| 42:4.0.1.1.8.11.100.6 | SECTION 438.930
| 438.930 Compliance dates. | |