Title 42

SECTION 475.105

475.105 Prohibition against contracting with health care facilities, affiliates, and payor organizations.

§ 475.105 Prohibition against contracting with health care facilities, affiliates, and payor organizations.

(a) Basic rule. Except as permitted under paragraph (a)(3) of this section, the following are not eligible for QIO contracts:

(1) A health care facility in the QIO area.

(2) A health care facility affiliate; that is, an organization in which more than 20 percent of the members of the governing body are also either a governing body member, officer, partner, five percent or more owner, or managing employee in a health care facility in the QIO area.

(3) A payor organization, unless the Secretary determines that -

(i) There is no other entity available for an area with which the Secretary can enter into a contract under this part; or

(ii) A payor organization is a more qualified entity to perform one or more of the functions of a QIO described in § 475.101(b), meets all other requirements and standards of this part, and demonstrates to the satisfaction of CMS that, in performing QIO activities, the payor organization will act with complete objectivity and independence from its payor program.

(b) [Reserved]

(c) Subcontracting. A QIO must not subcontract with a health care facility to perform any case review activities except for the review of the quality of care.

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