Title 42

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 Authority:42 U.S.C. 1302 and 1395hh, and 300e, 300e-5, and 300e-9, and 31 U.S.C. 9701.

• Authority: 42 U.S.C. 1302 and 1395hh, and 300e, 300e-5, and 300e-9, and 31 U.S.C. 9701.

42:3.0.1.1.4.1	SUBPART A	Subpart A - General Provisions
42:3.0.1.1.4.1.5.1	SECTION 417.1	417.1 Definitions.
42:3.0.1.1.4.1.5.2	SECTION 417.2	417.2 Basis and scope.
42:3.0.1.1.4.2	SUBPART B	Subpart B - Qualified Health Maintenance Organizations: Services
42:3.0.1.1.4.2.5.1	SECTION 417.101	417.101 Health benefits plan: Basic health services.
42:3.0.1.1.4.2.5.2	SECTION 417.102	417.102 Health benefits plan: Supplemental health services.
42:3.0.1.1.4.2.5.3	SECTION 417.103	417.103 Providers of basic and supplemental health services.
42:3.0.1.1.4.2.5.4	SECTION 417.104	417.104 Payment for basic health services.
42:3.0.1.1.4.2.5.5	SECTION 417.105	417.105 Payment for supplemental health services.
42:3.0.1.1.4.2.5.6	SECTION 417.106	417.106 Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services.
42:3.0.1.1.4.3	SUBPART C	Subpart C - Qualified Health Maintenance Organizations: Organization and Operation
42:3.0.1.1.4.3.5.1	SECTION 417.120	417.120 Fiscally sound operation and assumption of financial risk.
42:3.0.1.1.4.3.5.2	SECTION 417.122	417.122 Protection of enrollees.
42:3.0.1.1.4.3.5.3	SECTION 417.124	417.124 Administration and management.
42:3.0.1.1.4.3.5.4	SECTION 417.126	417.126 Recordkeeping and reporting requirements.
42:3.0.1.1.4.4	SUBPART D	Subpart D - Application for Federal Qualification
42:3.0.1.1.4.4.5.1	SECTION 417.140	417.140 Scope.
42:3.0.1.1.4.4.5.2	SECTION 417.142	417.142 Requirements for qualification.
42:3.0.1.1.4.4.5.3	SECTION 417.143	417.143 Application requirements.
42:3.0.1.1.4.4.5.4	SECTION 417.144	417.144 Evaluation and determination procedures.
42:3.0.1.1.4.5	SUBPART E	Subpart E - Inclusion of Qualified Health Maintenance Organizations in Employee Health Benefits Plans
42:3.0.1.1.4.5.5.1	SECTION 417.150	417.150 Definitions.
42:3.0.1.1.4.5.5.2	SECTION 417.151	417.151 Applicability.
42:3.0.1.1.4.5.5.3	SECTION 417.153	417.153 Offer of HMO alternative.
42:3.0.1.1.4.5.5.4	SECTION 417.155	417.155 How the HMO option must be included in the health benefits plan.
42:3.0.1.1.4.5.5.5	SECTION 417.156	417.156 When the HMO must be offered to employees.
42:3.0.1.1.4.5.5.6	SECTION 417.157	417.157 Contributions for the HMO alternative.
42:3.0.1.1.4.5.5.7	SECTION 417.158	417.158 Payroll deductions.
42:3.0.1.1.4.5.5.8	SECTION 417.159	417.159 Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway Labor Act.
42:3.0.1.1.4.6	SUBPART F	Subpart F - Continued Regulation of Federally Qualified Health Maintenance Organizations
42:3.0.1.1.4.6.5.1	SECTION 417.160	417.160 Applicability.
42:3.0.1.1.4.6.5.2	SECTION 417.161	417.161 Compliance with assurances.
42:3.0.1.1.4.6.5.3	SECTION 417.162	417.162 Reporting requirements.
42:3.0.1.1.4.6.5.4	SECTION 417.163	417.163 Enforcement procedures.
42:3.0.1.1.4.6.5.5	SECTION 417.164	417.164 Effect of revocation of qualification on inclusion in employee's health benefit plans.
42:3.0.1.1.4.6.5.6	SECTION 417.165	417.165 Reapplication for qualification.
42:3.0.1.1.4.6.5.7	SECTION 417.166	417.166 Waiver of assurances.
42:3.0.1.1.4.7	SUBPART G	Subparts G-I [Reserved]
42:3.0.1.1.4.8	SUBPART J	Subpart J - Qualifying Conditions for Medicare Contracts
42:3.0.1.1.4.8.5.1	SECTION 417.400	417.400 Basis and scope.
42:3.0.1.1.4.8.5.2	SECTION 417.401	417.401 Definitions.
42:3.0.1.1.4.8.5.3	SECTION 417.402	417.402 Effective date of initial regulations.
42:3.0.1.1.4.8.5.4	SECTION 417.404	417.404 General requirements.
42:3.0.1.1.4.8.5.5	SECTION 417.406	417.406 Application and determination.
42:3.0.1.1.4.8.5.6	SECTION 417.407	417.407 Requirements for a Competitive Medical Plan (CMP).
42:3.0.1.1.4.8.5.7	SECTION 417.408	417.408 Contract application process.
42:3.0.1.1.4.8.5.8	SECTION 417.410	417.410 Qualifying conditions: General rules.
42:3.0.1.1.4.8.5.9	SECTION 417.412	417.412 Qualifying condition: Administration and management.
42:3.0.1.1.4.8.5.10	SECTION 417.413	417.413 Qualifying condition: Operating experience and enrollment.
42:3.0.1.1.4.8.5.11	SECTION 417.414	417.414 Qualifying condition: Range of services.
42:3.0.1.1.4.8.5.12	SECTION 417.416	417.416 Qualifying condition: Furnishing of services.
42:3.0.1.1.4.8.5.13	SECTION 417.418	417.418 Qualifying condition: Quality assurance program.
42:3.0.1.1.4.9	SUBPART K	Subpart K - Enrollment, Entitlement, and Disenrollment under Medicare Contract
42:3.0.1.1.4.9.5.1	SECTION 417.420	417.420 Basic rules on enrollment and entitlement.
42:3.0.1.1.4.9.5.2	SECTION 417.422	417.422 Eligibility to enroll in an HMO or CMP.
42:3.0.1.1.4.9.5.3	SECTION 417.423	417.423 Special rules: ESRD and hospice patients.
42:3.0.1.1.4.9.5.4	SECTION 417.424	417.424 Denial of enrollment.
42:3.0.1.1.4.9.5.5	SECTION 417.426	417.426 Open enrollment requirements.
42:3.0.1.1.4.9.5.6	SECTION 417.427	417.427 Extending MA and Part D program disclosure requirements to section 1876 cost contract plans.
42:3.0.1.1.4.9.5.7	SECTION 417.428	417.428 Marketing activities.
42:3.0.1.1.4.9.5.8	SECTION 417.430	417.430 Application procedures.
42:3.0.1.1.4.9.5.9	SECTION 417.432	417.432 Conversion of enrollment.
42:3.0.1.1.4.9.5.10	SECTION 417.434	417.434 Reenrollment.
42:3.0.1.1.4.9.5.11	SECTION 417.436	417.436 Rules for enrollees.
42:3.0.1.1.4.9.5.12	SECTION 417.440	417.440 Entitlement to health care services from an HMO or CMP.
42:3.0.1.1.4.9.5.13	SECTION 417.442	417.442 Risk HMO's and CMP's: Conditions for provision of additional benefits.
42:3.0.1.1.4.9.5.14	SECTION 417.444	417.444 Special rules for certain enrollees of risk HMOs and CMPs.
42:3.0.1.1.4.9.5.15	SECTION 417.446	417.446 [Reserved]
42:3.0.1.1.4.9.5.16	SECTION 417.448	417.448 Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.
42:3.0.1.1.4.9.5.17	SECTION 417.450	417.450 Effective date of coverage.
42:3.0.1.1.4.9.5.18	SECTION 417.452	417.452 Liability of Medicare enrollees.
42:3.0.1.1.4.9.5.19	SECTION 417.454	417.454 Charges to Medicare enrollees.
42:3.0.1.1.4.9.5.20	SECTION 417.456	417.456 Refunds to Medicare enrollees.
42:3.0.1.1.4.9.5.21	SECTION 417.458	417.458 Recoupment of uncollected deductible and coinsurance amounts.
42:3.0.1.1.4.9.5.22	SECTION 417.460	417.460 Disenrollment of beneficiaries by an HMO or CMP.
42:3.0.1.1.4.9.5.23	SECTION 417.461	417.461 Disenrollment by the enrollee.
42:3.0.1.1.4.9.5.24	SECTION 417.464	417.464 End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract.
42:3.0.1.1.4.10	SUBPART L	Subpart L - Medicare Contract Requirements
42:3.0.1.1.4.10.5.1	SECTION 417.470	417.470 Basis and scope.
42:3.0.1.1.4.10.5.2	SECTION 417.472	417.472 Basic contract requirements.
42:3.0.1.1.4.10.5.3	SECTION 417.474	417.474 Effective date and term of contract.
42:3.0.1.1.4.10.5.4	SECTION 417.476	417.476 Waived conditions.
42:3.0.1.1.4.10.5.5	SECTION 417.478	417.478 Requirements of other laws and regulations.
42:3.0.1.1.4.10.5.6	SECTION 417.479	417.479 Requirements for physician incentive plans.
42:3.0.1.1.4.10.5.7	SECTION 417.480	417.480 Maintenance of records: Cost HMOs and CMPs.
42:3.0.1.1.4.10.5.8	SECTION 417.481	417.481 Maintenance of records: Risk HMOs and CMPs.
42:3.0.1.1.4.10.5.9	SECTION 417.482	417.482 Access to facilities and records.
42:3.0.1.1.4.10.5.10	SECTION 417.484	417.484 Requirement applicable to related entities.
42:3.0.1.1.4.10.5.11	SECTION 417.486	417.486 Disclosure of information and confidentiality.
42:3.0.1.1.4.10.5.12	SECTION 417.488	417.488 Notice of termination and of available alternatives: Risk contract.
42:3.0.1.1.4.10.5.13	SECTION 417.490	417.490 Renewal of contract.
42:3.0.1.1.4.10.5.14	SECTION 417.492	417.492 Nonrenewal of contract.
42:3.0.1.1.4.10.5.15	SECTION 417.494	417.494 Modification or termination of contract.
42:3.0.1.1.4.10.5.16	SECTION 417.496	417.496 xxx
42:3.0.1.1.4.10.5.17	SECTION 417.500	417.500 Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.
42:3.0.1.1.4.11	SUBPART M	Subpart M - Change of Ownership and Leasing of Facilities: Effect on Medicare Contract
42:3.0.1.1.4.11.5.1	SECTION 417.520	417.520 Effect on HMO and CMP contracts.
42:3.0.1.1.4.12	SUBPART N	Subpart N - Medicare Payment to HMOs and CMPs: General Rules
42:3.0.1.1.4.12.5.1	SECTION 417.524	417.524 Payment to HMOs or CMPs: General.
42:3.0.1.1.4.12.5.2	SECTION 417.526	417.526 Payment for covered services.
42:3.0.1.1.4.12.5.3	SECTION 417.528	417.528 Payment when Medicare is not primary payer.
42:3.0.1.1.4.13	SUBPART O	Subpart O - Medicare Payment: Cost Basis
42:3.0.1.1.4.13.5.1	SECTION 417.530	417.530 Basis and scope.
42:3.0.1.1.4.13.5.2	SECTION 417.531	417.531 Hospice care services.
42:3.0.1.1.4.13.5.3	SECTION 417.532	417.532 General considerations.
42:3.0.1.1.4.13.5.4	SECTION 417.533	417.533 Part B carrier responsibilities.
42:3.0.1.1.4.13.5.5	SECTION 417.534	417.534 Allowable costs.
42:3.0.1.1.4.13.5.6	SECTION 417.536	417.536 Cost payment principles.
42:3.0.1.1.4.13.5.7	SECTION 417.538	417.538 Enrollment and marketing costs.
42:3.0.1.1.4.13.5.8	SECTION 417.540	417.540 Enrollment costs.
42:3.0.1.1.4.13.5.9	SECTION 417.542	417.542 Reinsurance costs.
42:3.0.1.1.4.13.5.10	SECTION 417.544	417.544 Physicians' services furnished directly by the HMO or CMP.
42:3.0.1.1.4.13.5.11	SECTION 417.546	417.546 Physicians' services and other Part B supplier services furnished under arrangements.
42:3.0.1.1.4.13.5.12	SECTION 417.548	417.548 Provider services through arrangements.
42:3.0.1.1.4.13.5.13	SECTION 417.550	417.550 Special Medicare program requirements.
42:3.0.1.1.4.13.5.14	SECTION 417.552	417.552 Cost apportionment: General provisions.
42:3.0.1.1.4.13.5.15	SECTION 417.554	417.554 Apportionment: Provider services furnished directly by the HMO or CMP.
42:3.0.1.1.4.13.5.16	SECTION 417.556	417.556 Apportionment: Provider services furnished by the HMO or CMP through arrangements with others.
42:3.0.1.1.4.13.5.17	SECTION 417.558	417.558 Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility.
42:3.0.1.1.4.13.5.18	SECTION 417.560	417.560 Apportionment: Part B physician and supplier services.
42:3.0.1.1.4.13.5.19	SECTION 417.564	417.564 Apportionment and allocation of administrative and general costs.
42:3.0.1.1.4.13.5.20	SECTION 417.566	417.566 Other methods of allocation and apportionment.
42:3.0.1.1.4.13.5.21	SECTION 417.568	417.568 Adequate financial records, statistical data, and cost finding.
42:3.0.1.1.4.13.5.22	SECTION 417.570	417.570 Interim per capita payments.
42:3.0.1.1.4.13.5.23	SECTION 417.572	417.572 Budget and enrollment forecast and interim reports.
42:3.0.1.1.4.13.5.24	SECTION 417.574	417.574 Interim settlement.
42:3.0.1.1.4.13.5.25	SECTION 417.576	417.576 Final settlement.
42:3.0.1.1.4.14	SUBPART P	Subpart P - Medicare Payment: Risk Basis
42:3.0.1.1.4.14.5.1	SECTION 417.580	417.580 Basis and scope.
42:3.0.1.1.4.14.5.2	SECTION 417.582	417.582 Definitions.
42:3.0.1.1.4.14.5.3	SECTION 417.584	417.584 Payment to HMOs or CMPs with risk contracts.
42:3.0.1.1.4.14.5.4	SECTION 417.585	417.585 Special rules: Hospice care.
42:3.0.1.1.4.14.5.5	SECTION 417.588	417.588 Computation of adjusted average per capita cost (AAPCC).
42:3.0.1.1.4.14.5.6	SECTION 417.590	417.590 Computation of the average of the per capita rates of payment.
42:3.0.1.1.4.14.5.7	SECTION 417.592	417.592 Additional benefits requirement.
42:3.0.1.1.4.14.5.8	SECTION 417.594	417.594 Computation of adjusted community rate (ACR).
42:3.0.1.1.4.14.5.9	SECTION 417.596	417.596 Establishment of a benefit stabilization fund.
42:3.0.1.1.4.14.5.10	SECTION 417.597	417.597 Withdrawal from a benefit stabilization fund.
42:3.0.1.1.4.14.5.11	SECTION 417.598	417.598 Annual enrollment reconciliation.
42:3.0.1.1.4.15	SUBPART Q	Subpart Q - Beneficiary Appeals
42:3.0.1.1.4.15.5.1	SECTION 417.600	417.600 Basis and scope.
42:3.0.1.1.4.16	SUBPART R	Subpart R - Medicare Contract Appeals
42:3.0.1.1.4.16.5.1	SECTION 417.640	417.640 Applicability.
42:3.0.1.1.4.17	SUBPART S	Subparts S-T [Reserved]
42:3.0.1.1.4.18	SUBPART U	Subpart U - Health Care Prepayment Plans
42:3.0.1.1.4.18.5.1	SECTION 417.800	417.800 Payment to HCPPs: Definitions and basic rules.
42:3.0.1.1.4.18.5.2	SECTION 417.801	417.801 Agreements between CMS and health care prepayment plans.
42:3.0.1.1.4.18.5.3	SECTION 417.802	417.802 Allowable costs.
42:3.0.1.1.4.18.5.4	SECTION 417.804	417.804 Cost apportionment.
42:3.0.1.1.4.18.5.5	SECTION 417.806	417.806 Financial records, statistical data, and cost finding.
42:3.0.1.1.4.18.5.6	SECTION 417.808	417.808 Interim per capita payments.
42:3.0.1.1.4.18.5.7	SECTION 417.810	417.810 Final settlement.
42:3.0.1.1.4.18.5.8	SECTION 417.830	417.830 Scope of regulations on beneficiary appeals.
42:3.0.1.1.4.18.5.9	SECTION 417.832	417.832 Applicability of requirements and procedures.
42:3.0.1.1.4.18.5.10	SECTION 417.834	417.834 Responsibility for establishing administrative review procedures.
42:3.0.1.1.4.18.5.11	SECTION 417.836	417.836 Written description of administrative review procedures.
42:3.0.1.1.4.18.5.12	SECTION 417.838	417.838 Organization determinations.
42:3.0.1.1.4.18.5.13	SECTION 417.840	417.840 Administrative review procedures.
42:3.0.1.1.4.19	SUBPART V	Subpart V - Administration of Outstanding Loans and Loan Guarantees
42:3.0.1.1.4.19.5.1	SECTION 417.910	417.910 Applicability.
42:3.0.1.1.4.19.5.2	SECTION 417.911	417.911 Definitions.
42:3.0.1.1.4.19.5.3	SECTION 417.920	417.920 Planning and initial development.
42:3.0.1.1.4.19.5.4	SECTION 417.930	417.930 Initial costs of operation.
42:3.0.1.1.4.19.5.5	SECTION 417.931	417.931 [Reserved]
42:3.0.1.1.4.19.5.6	SECTION 417.934	417.934 Reserve requirement.
42:3.0.1.1.4.19.5.7	SECTION 417.937	417.937 Loan and loan guarantee provisions.
42:3.0.1.1.4.19.5.8	SECTION 417.940	417.940 Civil action to enforce compliance with assurances.

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