Title 42

PART 438

Part 438 - Managed Care

PART 438 - MANAGED CARE Authority:42 U.S.C. 1302. Link to an amendment published at 85 FR 25635, May 1, 2020. Source:67 FR 41095, June 14, 2002, unless otherwise noted.

42:4.0.1.1.8.1SUBPART A
Subpart A - General Provisions
42:4.0.1.1.8.1.100.1SECTION 438.1
   438.1 Basis and scope.
42:4.0.1.1.8.1.100.2SECTION 438.2
   438.2 Definitions.
42:4.0.1.1.8.1.100.3SECTION 438.3
   438.3 Standard contract requirements.
42:4.0.1.1.8.1.100.4SECTION 438.4
   438.4 Actuarial soundness.
42:4.0.1.1.8.1.100.5SECTION 438.5
   438.5 Rate development standards.
42:4.0.1.1.8.1.100.6SECTION 438.6
   438.6 Special contract provisions related to payment.
42:4.0.1.1.8.1.100.7SECTION 438.7
   438.7 Rate certification submission.
42:4.0.1.1.8.1.100.8SECTION 438.8
   438.8 Medical loss ratio (MLR) standards.
42:4.0.1.1.8.1.100.9SECTION 438.9
   438.9 Provisions that apply to non-emergency medical transportation PAHPs.
42:4.0.1.1.8.1.100.10SECTION 438.10
   438.10 Information requirements.
42:4.0.1.1.8.1.100.11SECTION 438.12
   438.12 Provider discrimination prohibited.
42:4.0.1.1.8.1.100.12SECTION 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).
42:4.0.1.1.8.2SUBPART B
Subpart B - State Responsibilities
42:4.0.1.1.8.2.100.1SECTION 438.50
   438.50 State Plan requirements.
42:4.0.1.1.8.2.100.2SECTION 438.52
   438.52 Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities.
42:4.0.1.1.8.2.100.3SECTION 438.54
   438.54 Managed care enrollment.
42:4.0.1.1.8.2.100.4SECTION 438.56
   438.56 Disenrollment: Requirements and limitations.
42:4.0.1.1.8.2.100.5SECTION 438.58
   438.58 Conflict of interest safeguards.
42:4.0.1.1.8.2.100.6SECTION 438.60
   438.60 Prohibition of additional payments for services covered under MCO, PIHP or PAHP contracts.
42:4.0.1.1.8.2.100.7SECTION 438.62
   438.62 Continued services to enrollees.
42:4.0.1.1.8.2.100.8SECTION 438.66
   438.66 State monitoring requirements.
42:4.0.1.1.8.2.100.9SECTION 438.68
   438.68 Network adequacy standards.
42:4.0.1.1.8.2.100.10SECTION 438.70
   438.70 Stakeholder engagement when LTSS is delivered through a managed care program.
42:4.0.1.1.8.2.100.11SECTION 438.71
   438.71 Beneficiary support system.
42:4.0.1.1.8.2.100.12SECTION 438.74
   438.74 State oversight of the minimum MLR requirement.
42:4.0.1.1.8.3SUBPART C
Subpart C - Enrollee Rights and Protections
42:4.0.1.1.8.3.100.1SECTION 438.100
   438.100 Enrollee rights.
42:4.0.1.1.8.3.100.2SECTION 438.102
   438.102 Provider-enrollee communications.
42:4.0.1.1.8.3.100.3SECTION 438.104
   438.104 Marketing activities.
42:4.0.1.1.8.3.100.4SECTION 438.106
   438.106 Liability for payment.
42:4.0.1.1.8.3.100.5SECTION 438.108
   438.108 Cost sharing.
42:4.0.1.1.8.3.100.6SECTION 438.110
   438.110 Member advisory committee.
42:4.0.1.1.8.3.100.7SECTION 438.114
   438.114 Emergency and poststabilization services.
42:4.0.1.1.8.3.100.8SECTION 438.116
   438.116 Solvency standards.
42:4.0.1.1.8.4SUBPART D
Subpart D - MCO, PIHP and PAHP Standards
42:4.0.1.1.8.4.100.1SECTION 438.206
   438.206 Availability of services.
42:4.0.1.1.8.4.100.2SECTION 438.207
   438.207 Assurances of adequate capacity and services.
42:4.0.1.1.8.4.100.3SECTION 438.208
   438.208 Coordination and continuity of care.
42:4.0.1.1.8.4.100.4SECTION 438.210
   438.210 Coverage and authorization of services.
42:4.0.1.1.8.4.100.6SECTION 438.214
   438.214 Provider selection.
42:4.0.1.1.8.4.100.7SECTION 438.224
   438.224 Confidentiality.
42:4.0.1.1.8.4.100.8SECTION 438.228
   438.228 Grievance and appeal systems.
42:4.0.1.1.8.4.100.9SECTION 438.230
   438.230 Subcontractual relationships and delegation.
42:4.0.1.1.8.4.100.10SECTION 438.236
   438.236 Practice guidelines.
42:4.0.1.1.8.4.100.11SECTION 438.242
   438.242 Health information systems.
42:4.0.1.1.8.5SUBPART E
Subpart E - Quality Measurement and Improvement; External Quality Review
42:4.0.1.1.8.5.100.1SECTION 438.310
   438.310 Basis, scope, and applicability.
42:4.0.1.1.8.5.100.2SECTION 438.320
   438.320 Definitions.
42:4.0.1.1.8.5.100.3SECTION 438.330
   438.330 Quality assessment and performance improvement program.
42:4.0.1.1.8.5.100.4SECTION 438.332
   438.332 State review of the accreditation status of MCOs, PIHPs, and PAHPs.
42:4.0.1.1.8.5.100.5SECTION 438.334
   438.334 Medicaid managed care quality rating system.
42:4.0.1.1.8.5.100.6SECTION 438.340
   438.340 Managed care State quality strategy.
42:4.0.1.1.8.5.100.7SECTION 438.350
   438.350 External quality review.
42:4.0.1.1.8.5.100.8SECTION 438.352
   438.352 External quality review protocols.
42:4.0.1.1.8.5.100.9SECTION 438.354
   438.354 Qualifications of external quality review organizations.
42:4.0.1.1.8.5.100.10SECTION 438.356
   438.356 State contract options for external quality review.
42:4.0.1.1.8.5.100.11SECTION 438.358
   438.358 Activities related to external quality review.
42:4.0.1.1.8.5.100.12SECTION 438.360
   438.360 Nonduplication of mandatory activities with Medicare or accreditation review.
42:4.0.1.1.8.5.100.13SECTION 438.362
   438.362 Exemption from external quality review.
42:4.0.1.1.8.5.100.14SECTION 438.364
   438.364 External quality review results.
42:4.0.1.1.8.5.100.15SECTION 438.370
   438.370 Federal financial participation (FFP).
42:4.0.1.1.8.6SUBPART F
Subpart F - Grievance and Appeal System
42:4.0.1.1.8.6.100.1SECTION 438.400
   438.400 Statutory basis, definitions, and applicability.
42:4.0.1.1.8.6.100.3SECTION 438.402
   438.402 General requirements.
42:4.0.1.1.8.6.100.5SECTION 438.404
   438.404 Timely and adequate notice of adverse benefit determination.
42:4.0.1.1.8.6.100.6SECTION 438.406
   438.406 Handling of grievances and appeals.
42:4.0.1.1.8.6.100.7SECTION 438.408
   438.408 Resolution and notification: Grievances and appeals.
42:4.0.1.1.8.6.100.8SECTION 438.410
   438.410 Expedited resolution of appeals.
42:4.0.1.1.8.6.100.9SECTION 438.414
   438.414 Information about the grievance and appeal system to providers and subcontractors.
42:4.0.1.1.8.6.100.10SECTION 438.416
   438.416 Recordkeeping requirements.
42:4.0.1.1.8.6.100.11SECTION 438.420
   438.420 Continuation of benefits while the MCO, PIHP, or PAHP appeal and the State fair hearing are pending.
42:4.0.1.1.8.6.100.12SECTION 438.424
   438.424 Effectuation of reversed appeal resolutions.
42:4.0.1.1.8.7SUBPART G
Subpart G [Reserved]
42:4.0.1.1.8.8SUBPART H
Subpart H - Additional Program Integrity Safeguards
42:4.0.1.1.8.8.100.1SECTION 438.600
   438.600 Statutory basis, basic rule, and applicability.
42:4.0.1.1.8.8.100.2SECTION 438.602
   438.602 State responsibilities.
42:4.0.1.1.8.8.100.3SECTION 438.604
   438.604 Data, information, and documentation that must be submitted.
42:4.0.1.1.8.8.100.4SECTION 438.606
   438.606 Source, content, and timing of certification.
42:4.0.1.1.8.8.100.5SECTION 438.608
   438.608 Program integrity requirements under the contract.
42:4.0.1.1.8.8.100.6SECTION 438.610
   438.610 Prohibited affiliations.
42:4.0.1.1.8.9SUBPART I
Subpart I - Sanctions
42:4.0.1.1.8.9.100.1SECTION 438.700
   438.700 Basis for imposition of sanctions.
42:4.0.1.1.8.9.100.2SECTION 438.702
   438.702 Types of intermediate sanctions.
42:4.0.1.1.8.9.100.3SECTION 438.704
   438.704 Amounts of civil money penalties.
42:4.0.1.1.8.9.100.4SECTION 438.706
   438.706 Special rules for temporary management.
42:4.0.1.1.8.9.100.5SECTION 438.708
   438.708 Termination of an MCO, PCCM or PCCM entity contract.
42:4.0.1.1.8.9.100.6SECTION 438.710
   438.710 Notice of sanction and pre-termination hearing.
42:4.0.1.1.8.9.100.7SECTION 438.722
   438.722 Disenrollment during termination hearing process.
42:4.0.1.1.8.9.100.8SECTION 438.724
   438.724 Notice to CMS.
42:4.0.1.1.8.9.100.9SECTION 438.726
   438.726 State plan requirement.
42:4.0.1.1.8.9.100.10SECTION 438.730
   438.730 Sanction by CMS: Special rules for MCOs.
42:4.0.1.1.8.10SUBPART J
Subpart J - Conditions for Federal Financial Participation (FFP)
42:4.0.1.1.8.10.100.1SECTION 438.802
   438.802 Basic requirements.
42:4.0.1.1.8.10.100.2SECTION 438.806
   438.806 Prior approval.
42:4.0.1.1.8.10.100.3SECTION 438.808
   438.808 Exclusion of entities.
42:4.0.1.1.8.10.100.4SECTION 438.810
   438.810 Expenditures for enrollment broker services.
42:4.0.1.1.8.10.100.5SECTION 438.812
   438.812 Costs under risk and nonrisk contracts.
42:4.0.1.1.8.10.100.6SECTION 438.816
   438.816 Expenditures for the beneficiary support system for enrollees using LTSS.
42:4.0.1.1.8.10.100.7SECTION 438.818
   438.818 Enrollee encounter data.
42:4.0.1.1.8.11SUBPART K
Subpart K - Parity in Mental Health and Substance Use Disorder Benefits
42:4.0.1.1.8.11.100.1SECTION 438.900
   438.900 Meaning of terms.
42:4.0.1.1.8.11.100.2SECTION 438.905
   438.905 Parity requirements for aggregate lifetime and annual dollar limits.
42:4.0.1.1.8.11.100.3SECTION 438.910
   438.910 Parity requirements for financial requirements and treatment limitations.
42:4.0.1.1.8.11.100.4SECTION 438.915
   438.915 Availability of information.
42:4.0.1.1.8.11.100.5SECTION 438.920
   438.920 Applicability.
42:4.0.1.1.8.11.100.6SECTION 438.930
   438.930 Compliance dates.