Title 42

Volume 4 CHAPTER IV SUBCHAP C

Subchapter C - Medical Assistance Programs

42:4.0.1.1.1PART 430
PART 430 - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
42:4.0.1.1.1.1SUBPART A
Subpart A - Introduction; General Provisions
42:4.0.1.1.1.1.1.1SECTION 430.0
     430.0 Program description.
42:4.0.1.1.1.1.1.2SECTION 430.1
     430.1 Scope of subchapter C.
42:4.0.1.1.1.1.1.3SECTION 430.2
     430.2 Other applicable Federal regulations.
42:4.0.1.1.1.1.1.4SECTION 430.3
     430.3 Appeals under Medicaid.
42:4.0.1.1.1.1.1.5SECTION 430.5
     430.5 Definitions.
42:4.0.1.1.1.2SUBPART B
Subpart B - State Plans
42:4.0.1.1.1.2.1.1SECTION 430.10
     430.10 The State plan.
42:4.0.1.1.1.2.1.2SECTION 430.12
     430.12 Submittal of State plans and plan amendments.
42:4.0.1.1.1.2.1.3SECTION 430.14
     430.14 Review of State plan material.
42:4.0.1.1.1.2.1.4SECTION 430.15
     430.15 Basis and authority for action on State plan material.
42:4.0.1.1.1.2.1.5SECTION 430.16
     430.16 Timing and notice of action on State plan material.
42:4.0.1.1.1.2.1.6SECTION 430.18
     430.18 Administrative review of action on State plan material.
42:4.0.1.1.1.2.1.7SECTION 430.20
     430.20 Effective dates of State plans and plan amendments.
42:4.0.1.1.1.2.1.8SECTION 430.25
     430.25 Waivers of State plan requirements.
42:4.0.1.1.1.3SUBPART C
Subpart C - Grants; Reviews and Audits; Withholding for Failure To Comply; Deferral and Disallowance of Claims; Reduction of Federal Medicaid Payments
42:4.0.1.1.1.3.1.1SECTION 430.30
     430.30 Grants procedures.
42:4.0.1.1.1.3.1.2SECTION 430.32
     430.32 Program reviews.
42:4.0.1.1.1.3.1.3SECTION 430.33
     430.33 Audits.
42:4.0.1.1.1.3.1.4SECTION 430.35
     430.35 Withholding of payment for failure to comply with Federal requirements.
42:4.0.1.1.1.3.1.5SECTION 430.38
     430.38 Judicial review.
42:4.0.1.1.1.3.1.6SECTION 430.40
     430.40 Deferral of claims for FFP.
42:4.0.1.1.1.3.1.7SECTION 430.42
     430.42 Disallowance of claims for FFP.
42:4.0.1.1.1.3.1.8SECTION 430.45
     430.45 Reduction of Federal Medicaid payments.
42:4.0.1.1.1.3.1.9SECTION 430.48
     430.48 Repayment of Federal funds by installments.
42:4.0.1.1.1.4SUBPART D
Subpart D - Hearings on Conformity of State Medicaid Plans and Practice to Federal Requirements
42:4.0.1.1.1.4.1.1SECTION 430.60
     430.60 Scope.
42:4.0.1.1.1.4.1.2SECTION 430.62
     430.62 Records to be public.
42:4.0.1.1.1.4.1.3SECTION 430.63
     430.63 Filing and service of papers.
42:4.0.1.1.1.4.1.4SECTION 430.64
     430.64 Suspension of rules.
42:4.0.1.1.1.4.1.5SECTION 430.66
     430.66 Designation of presiding officer for hearing.
42:4.0.1.1.1.4.1.6SECTION 430.70
     430.70 Notice of hearing or opportunity for hearing.
42:4.0.1.1.1.4.1.7SECTION 430.72
     430.72 Time and place of hearing.
42:4.0.1.1.1.4.1.8SECTION 430.74
     430.74 Issues at hearing.
42:4.0.1.1.1.4.1.9SECTION 430.76
     430.76 Parties to the hearing.
42:4.0.1.1.1.4.1.10SECTION 430.80
     430.80 Authority of the presiding officer.
42:4.0.1.1.1.4.1.11SECTION 430.83
     430.83 Rights of parties.
42:4.0.1.1.1.4.1.12SECTION 430.86
     430.86 Discovery.
42:4.0.1.1.1.4.1.13SECTION 430.88
     430.88 Evidence.
42:4.0.1.1.1.4.1.14SECTION 430.90
     430.90 Exclusion from hearing for misconduct.
42:4.0.1.1.1.4.1.15SECTION 430.92
     430.92 Unsponsored written material.
42:4.0.1.1.1.4.1.16SECTION 430.94
     430.94 Official transcript.
42:4.0.1.1.1.4.1.17SECTION 430.96
     430.96 Record for decision.
42:4.0.1.1.1.4.1.18SECTION 430.100
     430.100 Posthearing briefs.
42:4.0.1.1.1.4.1.19SECTION 430.102
     430.102 Decisions following hearing.
42:4.0.1.1.1.4.1.20SECTION 430.104
     430.104 Decisions that affect FFP.
42:4.0.1.1.2PART 431
PART 431 - STATE ORGANIZATION AND GENERAL ADMINISTRATION
42:4.0.1.1.2.0.8.1SECTION 431.1
     431.1 Purpose.
42:4.0.1.1.2.1SUBPART A
Subpart A - Single State Agency
42:4.0.1.1.2.1.8.1SECTION 431.10
     431.10 Single State agency.
42:4.0.1.1.2.1.8.2SECTION 431.11
     431.11 Organization for administration.
42:4.0.1.1.2.1.8.3SECTION 431.12
     431.12 Medical care advisory committee.
42:4.0.1.1.2.1.8.4SECTION 431.15
     431.15 Methods of administration.
42:4.0.1.1.2.1.8.5SECTION 431.16
     431.16 Reports.
42:4.0.1.1.2.1.8.6SECTION 431.17
     431.17 Maintenance of records.
42:4.0.1.1.2.1.8.7SECTION 431.18
     431.18 Availability of agency program manuals.
42:4.0.1.1.2.1.8.8SECTION 431.20
     431.20 Advance directives.
42:4.0.1.1.2.2SUBPART B
Subpart B - General Administrative Requirements
42:4.0.1.1.2.2.8.1SECTION 431.40
     431.40 Basis and scope.
42:4.0.1.1.2.2.8.2SECTION 431.50
     431.50 Statewide operation.
42:4.0.1.1.2.2.8.3SECTION 431.51
     431.51 Free choice of providers.
42:4.0.1.1.2.2.8.4SECTION 431.52
     431.52 Payments for services furnished out of State.
42:4.0.1.1.2.2.8.5SECTION 431.53
     431.53 Assurance of transportation.
42:4.0.1.1.2.2.8.6SECTION 431.54
     431.54 Exceptions to certain State plan requirements.
42:4.0.1.1.2.2.8.7SECTION 431.55
     431.55 Waiver of other Medicaid requirements.
42:4.0.1.1.2.2.8.8SECTION 431.56
     431.56 Special waiver provisions applicable to American Samoa and the Northern Mariana Islands.
42:4.0.1.1.2.2.8.9SECTION 431.60
     431.60 xxx
42:4.0.1.1.2.2.8.10SECTION 431.70
     431.70 xxx
42:4.0.1.1.2.3SUBPART C
Subpart C - Administrative Requirements: Provider Relations
42:4.0.1.1.2.3.8.1SECTION 431.105
     431.105 Consultation to medical facilities.
42:4.0.1.1.2.3.8.2SECTION 431.107
     431.107 Required provider agreement.
42:4.0.1.1.2.3.8.3SECTION 431.108
     431.108 Effective date of provider agreements.
42:4.0.1.1.2.3.8.4SECTION 431.110
     431.110 Participation by Indian Health Service facilities.
42:4.0.1.1.2.3.8.5SECTION 431.115
     431.115 Disclosure of survey information and provider or contractor evaluation.
42:4.0.1.1.2.3.8.6SECTION 431.120
     431.120 State requirements with respect to nursing facilities.
42:4.0.1.1.2.4SUBPART D
Subpart D - Appeals Process for NFs and ICFs/IID
42:4.0.1.1.2.4.8.1SECTION 431.151
     431.151 Scope and applicability.
42:4.0.1.1.2.4.8.2SECTION 431.152
     431.152 State plan requirements.
42:4.0.1.1.2.4.8.3SECTION 431.153
     431.153 Evidentiary hearing.
42:4.0.1.1.2.4.8.4SECTION 431.154
     431.154 Informal reconsideration for ICFs/IID.
42:4.0.1.1.2.5SUBPART E
Subpart E - Fair Hearings for Applicants and Beneficiaries
42:4.0.1.1.2.5.8SUBJGRP 8
  General Provisions
42:4.0.1.1.2.5.8.1SECTION 431.200
     431.200 Basis and scope.
42:4.0.1.1.2.5.8.2SECTION 431.201
     431.201 Definitions.
42:4.0.1.1.2.5.8.3SECTION 431.202
     431.202 State plan requirements.
42:4.0.1.1.2.5.8.4SECTION 431.205
     431.205 Provision of hearing system.
42:4.0.1.1.2.5.8.5SECTION 431.206
     431.206 Informing applicants and beneficiaries.
42:4.0.1.1.2.5.9SUBJGRP 9
  Notice
42:4.0.1.1.2.5.9.6SECTION 431.210
     431.210 Content of notice.
42:4.0.1.1.2.5.9.7SECTION 431.211
     431.211 Advance notice.
42:4.0.1.1.2.5.9.8SECTION 431.213
     431.213 Exceptions from advance notice.
42:4.0.1.1.2.5.9.9SECTION 431.214
     431.214 Notice in cases of probable fraud.
42:4.0.1.1.2.5.10SUBJGRP 10
  Right to Hearing
42:4.0.1.1.2.5.10.10SECTION 431.220
     431.220 When a hearing is required.
42:4.0.1.1.2.5.10.11SECTION 431.221
     431.221 Request for hearing.
42:4.0.1.1.2.5.10.12SECTION 431.222
     431.222 Group hearings.
42:4.0.1.1.2.5.10.13SECTION 431.223
     431.223 Denial or dismissal of request for a hearing.
42:4.0.1.1.2.5.10.14SECTION 431.224
     431.224 Expedited appeals.
42:4.0.1.1.2.5.11SUBJGRP 11
  Procedures
42:4.0.1.1.2.5.11.15SECTION 431.230
     431.230 Maintaining services.
42:4.0.1.1.2.5.11.16SECTION 431.231
     431.231 Reinstating services.
42:4.0.1.1.2.5.11.17SECTION 431.232
     431.232 Adverse decision of local evidentiary hearing.
42:4.0.1.1.2.5.11.18SECTION 431.233
     431.233 State agency hearing after adverse decision of local evidentiary hearing.
42:4.0.1.1.2.5.11.19SECTION 431.240
     431.240 Conducting the hearing.
42:4.0.1.1.2.5.11.20SECTION 431.241
     431.241 Matters to be considered at the hearing.
42:4.0.1.1.2.5.11.21SECTION 431.242
     431.242 Procedural rights of the applicant or beneficiary.
42:4.0.1.1.2.5.11.22SECTION 431.243
     431.243 Parties in cases involving an eligibility determination.
42:4.0.1.1.2.5.11.23SECTION 431.244
     431.244 Hearing decisions.
42:4.0.1.1.2.5.11.24SECTION 431.245
     431.245 Notifying the applicant or beneficiary of a State agency decision.
42:4.0.1.1.2.5.11.25SECTION 431.246
     431.246 Corrective action.
42:4.0.1.1.2.5.12SUBJGRP 12
  Federal Financial Participation
42:4.0.1.1.2.5.12.26SECTION 431.250
     431.250 Federal financial participation.
42:4.0.1.1.2.6SUBPART F
Subpart F - Safeguarding Information on Applicants and Beneficiaries
42:4.0.1.1.2.6.13.1SECTION 431.300
     431.300 Basis and purpose.
42:4.0.1.1.2.6.13.2SECTION 431.301
     431.301 State plan requirements.
42:4.0.1.1.2.6.13.3SECTION 431.302
     431.302 Purposes directly related to State plan administration.
42:4.0.1.1.2.6.13.4SECTION 431.303
     431.303 State authority for safeguarding information.
42:4.0.1.1.2.6.13.5SECTION 431.304
     431.304 Publicizing safeguarding requirements.
42:4.0.1.1.2.6.13.6SECTION 431.305
     431.305 Types of information to be safeguarded.
42:4.0.1.1.2.6.13.7SECTION 431.306
     431.306 Release of information.
42:4.0.1.1.2.6.13.8SECTION 431.307
     431.307 Distribution of information materials.
42:4.0.1.1.2.7SUBPART G
Subpart G - Section 1115 Demonstrations
42:4.0.1.1.2.7.13.1SECTION 431.400
     431.400 Basis and purpose.
42:4.0.1.1.2.7.13.2SECTION 431.404
     431.404 Definitions.
42:4.0.1.1.2.7.13.3SECTION 431.408
     431.408 State public notice process.
42:4.0.1.1.2.7.13.4SECTION 431.412
     431.412 Application procedures.
42:4.0.1.1.2.7.13.5SECTION 431.416
     431.416 Federal public notice and approval process.
42:4.0.1.1.2.7.13.6SECTION 431.420
     431.420 Monitoring and compliance.
42:4.0.1.1.2.7.13.7SECTION 431.424
     431.424 Evaluation requirements.
42:4.0.1.1.2.7.13.8SECTION 431.428
     431.428 Reporting requirements.
42:4.0.1.1.2.8SUBPART H
Subparts H-L [Reserved]
42:4.0.1.1.2.9SUBPART M
Subpart M - Relations With Other Agencies
42:4.0.1.1.2.9.13.1SECTION 431.610
     431.610 Relations with standard-setting and survey agencies.
42:4.0.1.1.2.9.13.2SECTION 431.615
     431.615 Relations with State health and vocational rehabilitation agencies and title V grantees.
42:4.0.1.1.2.9.13.3SECTION 431.620
     431.620 Agreement with State mental health authority or mental institutions.
42:4.0.1.1.2.9.13.4SECTION 431.621
     431.621 State requirements with respect to nursing facilities.
42:4.0.1.1.2.9.13.5SECTION 431.625
     431.625 Coordination of Medicaid with Medicare part B.
42:4.0.1.1.2.9.13.6SECTION 431.630
     431.630 Coordination of Medicaid with QIOs.
42:4.0.1.1.2.9.13.7SECTION 431.635
     431.635 Coordination of Medicaid with Special Supplemental Food Program for Women, Infants, and Children (WIC).
42:4.0.1.1.2.10SUBPART N
Subpart N - State Programs for Licensing Nursing Home Administrators
42:4.0.1.1.2.10.13.1SECTION 431.700
     431.700 Basis and purpose.
42:4.0.1.1.2.10.13.2SECTION 431.701
     431.701 Definitions.
42:4.0.1.1.2.10.13.3SECTION 431.702
     431.702 State plan requirement.
42:4.0.1.1.2.10.13.4SECTION 431.703
     431.703 Licensing requirement.
42:4.0.1.1.2.10.13.5SECTION 431.704
     431.704 Nursing homes designated by other terms.
42:4.0.1.1.2.10.13.6SECTION 431.705
     431.705 Licensing authority.
42:4.0.1.1.2.10.13.7SECTION 431.706
     431.706 Composition of licensing board.
42:4.0.1.1.2.10.13.8SECTION 431.707
     431.707 Standards.
42:4.0.1.1.2.10.13.9SECTION 431.708
     431.708 Procedures for applying standards.
42:4.0.1.1.2.10.13.10SECTION 431.709
     431.709 Issuance and revocation of license.
42:4.0.1.1.2.10.13.11SECTION 431.710
     431.710 Provisional licenses.
42:4.0.1.1.2.10.13.12SECTION 431.711
     431.711 Compliance with standards.
42:4.0.1.1.2.10.13.13SECTION 431.712
     431.712 Failure to comply with standards.
42:4.0.1.1.2.10.13.14SECTION 431.713
     431.713 Continuing study and investigation.
42:4.0.1.1.2.10.13.15SECTION 431.714
     431.714 Waivers.
42:4.0.1.1.2.10.13.16SECTION 431.715
     431.715 Federal financial participation.
42:4.0.1.1.2.11SUBPART O
Subpart O [Reserved]
42:4.0.1.1.2.12SUBPART P
Subpart P - Quality Control
42:4.0.1.1.2.12.13SUBJGRP 13
  Medicaid Eligibility Quality Control (MEQC) Program
42:4.0.1.1.2.12.13.1SECTION 431.800
     431.800 Basis and scope.
42:4.0.1.1.2.12.13.2SECTION 431.804
     431.804 Definitions.
42:4.0.1.1.2.12.13.3SECTION 431.806
     431.806 State requirements.
42:4.0.1.1.2.12.13.4SECTION 431.808
     431.808 Protection of beneficiary rights.
42:4.0.1.1.2.12.13.5SECTION 431.810
     431.810 Basic elements of the Medicaid Eligibility Quality Control (MEQC) Program.
42:4.0.1.1.2.12.13.6SECTION 431.812
     431.812 Review procedures.
42:4.0.1.1.2.12.13.7SECTION 431.814
     431.814 Pilot planning document.
42:4.0.1.1.2.12.13.8SECTION 431.816
     431.816 Case review completion deadlines and submittal of reports.
42:4.0.1.1.2.12.13.9SECTION 431.818
     431.818 Access to records.
42:4.0.1.1.2.12.13.10SECTION 431.820
     431.820 Corrective action under the MEQC program.
42:4.0.1.1.2.12.14SUBJGRP 14
  Medicaid Quality Control (MQC) Claims Processing Assessment System
42:4.0.1.1.2.12.14.11SECTION 431.830
     431.830 Basic elements of the Medicaid quality control (MQC) claims processing assessment system.
42:4.0.1.1.2.12.14.12SECTION 431.832
     431.832 Reporting requirements for claims processing assessment systems.
42:4.0.1.1.2.12.14.13SECTION 431.834
     431.834 Access to records: Claims processing assessment systems.
42:4.0.1.1.2.12.14.14SECTION 431.836
     431.836 Corrective action under the MQC claims processing assessment system.
42:4.0.1.1.2.13SUBPART Q
Subpart Q - Requirements for Estimating Improper Payments in Medicaid and CHIP
42:4.0.1.1.2.13.15.1SECTION 431.950
     431.950 Purpose.
42:4.0.1.1.2.13.15.2SECTION 431.954
     431.954 Basis and scope.
42:4.0.1.1.2.13.15.3SECTION 431.958
     431.958 Definitions and use of terms.
42:4.0.1.1.2.13.15.4SECTION 431.960
     431.960 Types of payment errors.
42:4.0.1.1.2.13.15.5SECTION 431.970
     431.970 Information submission and systems access requirements.
42:4.0.1.1.2.13.15.6SECTION 431.972
     431.972 Claims sampling procedures.
42:4.0.1.1.2.13.15.7SECTION 431.992
     431.992 Corrective action plan.
42:4.0.1.1.2.13.15.8SECTION 431.998
     431.998 Difference resolution and appeal process.
42:4.0.1.1.2.13.15.9SECTION 431.1002
     431.1002 Recoveries.
42:4.0.1.1.2.13.15.10SECTION 431.1010
     431.1010 Disallowance of Federal financial participation for erroneous State payments (for PERM review years ending after July 1, 2020).
42:4.0.1.1.3PART 432
PART 432 - STATE PERSONNEL ADMINISTRATION
42:4.0.1.1.3.1SUBPART A
Subpart A - General Provisions
42:4.0.1.1.3.1.15.1SECTION 432.1
     432.1 Basis and purpose.
42:4.0.1.1.3.1.15.2SECTION 432.2
     432.2 Definitions.
42:4.0.1.1.3.1.15.3SECTION 432.10
     432.10 Standards of personnel administration.
42:4.0.1.1.3.2SUBPART B
Subpart B - Training Programs; Subprofessional and Volunteer Programs
42:4.0.1.1.3.2.15.1SECTION 432.30
     432.30 Training programs: General requirements.
42:4.0.1.1.3.2.15.2SECTION 432.31
     432.31 Training and use of subprofessional staff.
42:4.0.1.1.3.2.15.3SECTION 432.32
     432.32 Training and use of volunteers.
42:4.0.1.1.3.3SUBPART C
Subpart C - Staffing and Training Expenditures
42:4.0.1.1.3.3.15.1SECTION 432.45
     432.45 Applicability of provisions in subpart.
42:4.0.1.1.3.3.15.2SECTION 432.50
     432.50 FFP: Staffing and training costs.
42:4.0.1.1.3.3.15.3SECTION 432.55
     432.55 Reporting training and administrative costs.
42:4.0.1.1.4PART 433
PART 433 - STATE FISCAL ADMINISTRATION
42:4.0.1.1.4.0.17.1SECTION 433.1
     433.1 Purpose.
42:4.0.1.1.4.1SUBPART A
Subpart A - Federal Matching and General Administration Provisions
42:4.0.1.1.4.1.17.1SECTION 433.8
     433.8 [Reserved]
42:4.0.1.1.4.1.17.2SECTION 433.10
     433.10 Rates of FFP for program services.
42:4.0.1.1.4.1.17.3SECTION 433.11
     433.11 Enhanced FMAP rate for children.
42:4.0.1.1.4.1.17.4SECTION 433.15
     433.15 Rates of FFP for administration.
42:4.0.1.1.4.1.17.5SECTION 433.32
     433.32 Fiscal policies and accountability.
42:4.0.1.1.4.1.17.6SECTION 433.34
     433.34 Cost allocation.
42:4.0.1.1.4.1.17.7SECTION 433.35
     433.35 Equipment - Federal financial participation.
42:4.0.1.1.4.1.17.8SECTION 433.36
     433.36 Liens and recoveries.
42:4.0.1.1.4.1.17.9SECTION 433.37
     433.37 Reporting provider payments to Internal Revenue Service.
42:4.0.1.1.4.1.17.10SECTION 433.38
     433.38 Interest charge on disallowed claims for FFP.
42:4.0.1.1.4.1.17.11SECTION 433.40
     433.40 Treatment of uncashed or cancelled (voided) Medicaid checks.
42:4.0.1.1.4.2SUBPART B
Subpart B - General Administrative Requirements State Financial Participation
42:4.0.1.1.4.2.17.1SECTION 433.50
     433.50 Basis, scope, and applicability.
42:4.0.1.1.4.2.17.2SECTION 433.51
     433.51 Public Funds as the State share of financial participation.
42:4.0.1.1.4.2.17.3SECTION 433.52
     433.52 General definitions.
42:4.0.1.1.4.2.17.4SECTION 433.53
     433.53 State plan requirements.
42:4.0.1.1.4.2.17.5SECTION 433.54
     433.54 Bona fide donations.
42:4.0.1.1.4.2.17.6SECTION 433.55
     433.55 Health care-related taxes defined.
42:4.0.1.1.4.2.17.7SECTION 433.56
     433.56 Classes of health care services and providers defined.
42:4.0.1.1.4.2.17.8SECTION 433.57
     433.57 General rules regarding revenues from provider-related donations and health care-related taxes.
42:4.0.1.1.4.2.17.9SECTION 433.58-433.60
     433.58-433.60 [Reserved]
42:4.0.1.1.4.2.17.10SECTION 433.66
     433.66 Permissible provider-related donations.
42:4.0.1.1.4.2.17.11SECTION 433.67
     433.67 Limitations on level of FFP for permissible provider-related donations.
42:4.0.1.1.4.2.17.12SECTION 433.68
     433.68 Permissible health care-related taxes.
42:4.0.1.1.4.2.17.13SECTION 433.70
     433.70 Limitation on level of FFP for revenues from health care-related taxes.
42:4.0.1.1.4.2.17.14SECTION 433.72
     433.72 Waiver provisions applicable to health care-related taxes.
42:4.0.1.1.4.2.17.15SECTION 433.74
     433.74 Reporting requirements.
42:4.0.1.1.4.3SUBPART C
Subpart C - Mechanized Claims Processing and Information Retrieval Systems
42:4.0.1.1.4.3.17.1SECTION 433.110
     433.110 Basis, purpose, and applicability.
42:4.0.1.1.4.3.17.2SECTION 433.111
     433.111 Definitions.
42:4.0.1.1.4.3.17.3SECTION 433.112
     433.112 FFP for design, development, installation or enhancement of mechanized processing and information retrieval systems.
42:4.0.1.1.4.3.17.4SECTION 433.114
     433.114 Procedures for obtaining initial approval; notice of decision.
42:4.0.1.1.4.3.17.5SECTION 433.116
     433.116 FFP for operation of mechanized claims processing and information retrieval systems.
42:4.0.1.1.4.3.17.6SECTION 433.117
     433.117 Initial approval of replacement systems.
42:4.0.1.1.4.3.17.7SECTION 433.119
     433.119 Conditions for reapproval; notice of decision.
42:4.0.1.1.4.3.17.8SECTION 433.120
     433.120 Procedures for reduction of FFP after reapproval review.
42:4.0.1.1.4.3.17.9SECTION 433.121
     433.121 Reconsideration of the decision to reduce FFP after reapproval review.
42:4.0.1.1.4.3.17.10SECTION 433.122
     433.122 Reapproval of a disapproved system.
42:4.0.1.1.4.3.17.11SECTION 433.123
     433.123 Notification of changes in system requirements, performance standards or other conditions for approval or reapproval.
42:4.0.1.1.4.3.17.12SECTION 433.127
     433.127 Termination of FFP for failure to provide access to claims processing and information retrieval systems.
42:4.0.1.1.4.3.17.13SECTION 433.131
     433.131 Waiver for noncompliance with conditions of approval and reapproval.
42:4.0.1.1.4.4SUBPART D
Subpart D - Third Party Liability
42:4.0.1.1.4.4.17SUBJGRP 17
  Assignment of Rights to Benefits
42:4.0.1.1.4.4.17.1SECTION 433.135
     433.135 Basis and purpose.
42:4.0.1.1.4.4.17.2SECTION 433.136
     433.136 Definitions.
42:4.0.1.1.4.4.17.3SECTION 433.137
     433.137 State plan requirements.
42:4.0.1.1.4.4.17.4SECTION 433.138
     433.138 Identifying liable third parties.
42:4.0.1.1.4.4.17.5SECTION 433.139
     433.139 Payment of claims.
42:4.0.1.1.4.4.17.6SECTION 433.140
     433.140 FFP and repayment of Federal share.
42:4.0.1.1.4.4.17.7SECTION 433.145
     433.145 Assignment of rights to benefits - State plan requirements.
42:4.0.1.1.4.4.17.8SECTION 433.146
     433.146 Rights assigned; assignment method.
42:4.0.1.1.4.4.17.9SECTION 433.147
     433.147 Cooperation in establishing the identity of a child's parents and in obtaining medical support and payments and in identifying and providing information to assist in pursuing third parties who may be liable to pay.
42:4.0.1.1.4.4.17.10SECTION 433.148
     433.148 Denial or termination of eligibility.
42:4.0.1.1.4.4.18SUBJGRP 18
  Cooperative Agreements and Incentive Payments
42:4.0.1.1.4.4.18.11SECTION 433.151
     433.151 Cooperative agreements and incentive payments - State plan requirements.
42:4.0.1.1.4.4.18.12SECTION 433.152
     433.152 Requirements for cooperative agreements for third party collections.
42:4.0.1.1.4.4.18.13SECTION 433.153
     433.153 Incentive payments to States and political subdivisions.
42:4.0.1.1.4.4.18.14SECTION 433.154
     433.154 Distribution of collections.
42:4.0.1.1.4.5SUBPART E
Subpart E - Methodologies for Determining Federal Share of Medicaid Expenditures for Adult Eligibility Group
42:4.0.1.1.4.5.19.1SECTION 433.202
     433.202 Scope.
42:4.0.1.1.4.5.19.2SECTION 433.204
     433.204 Definitions.
42:4.0.1.1.4.5.19.3SECTION 433.206
     433.206 Threshold methodology.
42:4.0.1.1.4.6SUBPART F
Subpart F - Refunding of Federal Share of Medicaid Overpayments to Providers
42:4.0.1.1.4.6.19.1SECTION 433.300
     433.300 Basis.
42:4.0.1.1.4.6.19.2SECTION 433.302
     433.302 Scope of subpart.
42:4.0.1.1.4.6.19.3SECTION 433.304
     433.304 Definitions.
42:4.0.1.1.4.6.19.4SECTION 433.310
     433.310 Applicability of requirements.
42:4.0.1.1.4.6.19.5SECTION 433.312
     433.312 Basic requirements for refunds.
42:4.0.1.1.4.6.19.6SECTION 433.316
     433.316 When discovery of overpayment occurs and its significance.
42:4.0.1.1.4.6.19.7SECTION 433.318
     433.318 Overpayments involving providers who are bankrupt or out of business.
42:4.0.1.1.4.6.19.8SECTION 433.320
     433.320 Procedures for refunds to CMS.
42:4.0.1.1.4.6.19.9SECTION 433.322
     433.322 Maintenance of Records.
42:4.0.1.1.5PART 434
PART 434 - CONTRACTS
42:4.0.1.1.5.1SUBPART A
Subpart A - General Provisions
42:4.0.1.1.5.1.19.1SECTION 434.1
     434.1 Basis and scope.
42:4.0.1.1.5.1.19.2SECTION 434.2
     434.2 Definitions.
42:4.0.1.1.5.1.19.3SECTION 434.4
     434.4 State plan requirement.
42:4.0.1.1.5.1.19.4SECTION 434.6
     434.6 General requirements for all contracts and subcontracts.
42:4.0.1.1.5.2SUBPART B
Subpart B - Contracts with Fiscal Agents and Private Nonmedical Institutions
42:4.0.1.1.5.2.19.1SECTION 434.10
     434.10 Contracts with fiscal agents.
42:4.0.1.1.5.2.19.2SECTION 434.12
     434.12 Contracts with private nonmedical institutions.
42:4.0.1.1.5.2.19.3SECTION 434.14
     434.14 [Reserved]
42:4.0.1.1.5.3SUBPART C
Subpart C [Reserved]
42:4.0.1.1.5.4SUBPART D
Subpart D - Contracts With Health Insuring Organizations
42:4.0.1.1.5.4.19.1SECTION 434.40
     434.40 Contract requirements.
42:4.0.1.1.5.5SUBPART E
Subpart E [Reserved]
42:4.0.1.1.5.6SUBPART F
Subpart F - Federal Financial Participation
42:4.0.1.1.5.6.19.1SECTION 434.70
     434.70 Conditions for Federal Financial Participation (FFP).
42:4.0.1.1.5.6.19.2SECTION 434.76
     434.76 Costs under fiscal agent contracts.
42:4.0.1.1.5.6.19.3SECTION 434.78
     434.78 Right to reconsideration of disallowance.
42:4.0.1.1.6PART 435
PART 435 - ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA
42:4.0.1.1.6.1SUBPART A
Subpart A - General Provisions and Definitions
42:4.0.1.1.6.1.48.1SECTION 435.2
     435.2 Purpose and applicability.
42:4.0.1.1.6.1.48.2SECTION 435.3
     435.3 Basis.
42:4.0.1.1.6.1.48.3SECTION 435.4
     435.4 Definitions and use of terms.
42:4.0.1.1.6.1.48.4SECTION 435.10
     435.10 State plan requirements.
42:4.0.1.1.6.2SUBPART B
Subpart B - Mandatory Coverage
42:4.0.1.1.6.2.48SUBJGRP 48
  Mandatory Coverage of Families and Children
42:4.0.1.1.6.2.48.1SECTION 435.100
     435.100 Scope.
42:4.0.1.1.6.2.48.2SECTION 435.110
     435.110 Parents and other caretaker relatives.
42:4.0.1.1.6.2.48.3SECTION 435.112
     435.112 Families terminated from AFDC because of increased earnings or hours of employment.
42:4.0.1.1.6.2.48.4SECTION 435.115
     435.115 Families with Medicaid eligibility extended because of increased collection of spousal support.
42:4.0.1.1.6.2.49SUBJGRP 49
  Mandatory Coverage of Pregnant Women, Children Under 19, and Newborn Children
42:4.0.1.1.6.2.49.5SECTION 435.116
     435.116 Pregnant women.
42:4.0.1.1.6.2.49.6SECTION 435.117
     435.117 Deemed newborn children.
42:4.0.1.1.6.2.50SUBJGRP 50
  Mandatory Coverage of Qualified Family Members
42:4.0.1.1.6.2.50.7SECTION 435.118
     435.118 Infants and children under age 19.
42:4.0.1.1.6.2.51SUBJGRP 51
  Mandatory Coverage for Individuals Age 19 Through 64
42:4.0.1.1.6.2.51.8SECTION 435.119
     435.119 Coverage for individuals age 19 or older and under age 65 at or below 133 percent FPL.
42:4.0.1.1.6.2.52SUBJGRP 52
  Mandatory Coverage of the Aged, Blind, and Disabled
42:4.0.1.1.6.2.52.9SECTION 435.120
     435.120 Individuals receiving SSI.
42:4.0.1.1.6.2.52.10SECTION 435.121
     435.121 Individuals in States using more restrictive requirements for Medicaid than the SSI requirements.
42:4.0.1.1.6.2.52.11SECTION 435.122
     435.122 Individuals who are ineligible for SSI or optional State supplements because of requirements that do not apply under title XIX of the Act.
42:4.0.1.1.6.2.52.12SECTION 435.130
     435.130 Individuals receiving mandatory State supplements.
42:4.0.1.1.6.2.52.13SECTION 435.131
     435.131 Individuals eligible as essential spouses in December 1973.
42:4.0.1.1.6.2.52.14SECTION 435.132
     435.132 Institutionalized individuals who were eligible in December 1973.
42:4.0.1.1.6.2.52.15SECTION 435.133
     435.133 Blind and disabled individuals eligible in December 1973.
42:4.0.1.1.6.2.52.16SECTION 435.134
     435.134 Individuals who would be eligible except for the increase in OASDI benefits under Pub. L. 92-336 (July 1, 1972).
42:4.0.1.1.6.2.52.17SECTION 435.135
     435.135 Individuals who become ineligible for cash assistance as a result of OASDI cost-of-living increases received after April 1977.
42:4.0.1.1.6.2.52.18SECTION 435.136
     435.136 State agency implementation requirements for one-time notice and annual review system.
42:4.0.1.1.6.2.52.19SECTION 435.137
     435.137 Disabled widows and widowers who would be eligible for SSI except for the increase in disability benefits resulting from elimination of the reduction factor under Pub. L. 98-21.
42:4.0.1.1.6.2.52.20SECTION 435.138
     435.138 Disabled widows and widowers aged 60 through 64 who would be eligible for SSI except for early receipt of social security benefits.
42:4.0.1.1.6.2.53SUBJGRP 53
  Mandatory Coverage of Certain Aliens
42:4.0.1.1.6.2.53.21SECTION 435.139
     435.139 Coverage for certain aliens.
42:4.0.1.1.6.2.54SUBJGRP 54
  Mandatory Coverage of Adoption Assistance and Foster Care Children
42:4.0.1.1.6.2.54.22SECTION 435.145
     435.145 Children with adoption assistance, foster care, or guardianship care under title IV-E.
42:4.0.1.1.6.2.54.23SECTION 435.150
     435.150 Former foster care children.
42:4.0.1.1.6.2.55SUBJGRP 55
  Mandatory Coverage of Special Groups
42:4.0.1.1.6.2.55.24SECTION 435.170
     435.170 Pregnant women eligible for extended or continuous eligibility.
42:4.0.1.1.6.2.55.25SECTION 435.172
     435.172 Continuous eligibility for hospitalized children.
42:4.0.1.1.6.3SUBPART C
Subpart C - Options for Coverage
42:4.0.1.1.6.3.56SUBJGRP 56
  Options for Coverage of Families and Children and the Aged, Blind, and Disabled
42:4.0.1.1.6.3.56.1SECTION 435.200
     435.200 Scope.
42:4.0.1.1.6.3.56.2SECTION 435.201
     435.201 Individuals included in optional groups.
42:4.0.1.1.6.3.56.3SECTION 435.210
     435.210 Optional eligibility for individuals who meet the income and resource requirements of the cash assistance programs.
42:4.0.1.1.6.3.56.4SECTION 435.211
     435.211 Optional eligibility for individuals who would be eligible for cash assistance if they were not in medical institutions.
42:4.0.1.1.6.3.56.5SECTION 435.212
     435.212 Individuals who would be ineligible if they were not enrolled in an MCO or PCCM.
42:4.0.1.1.6.3.56.6SECTION 435.213
     435.213 Optional eligibility for individuals needing treatment for breast or cervical cancer.
42:4.0.1.1.6.3.56.7SECTION 435.214
     435.214 Eligibility for Medicaid limited to family planning and related services.
42:4.0.1.1.6.3.56.8SECTION 435.215
     435.215 Individuals infected with tuberculosis.
42:4.0.1.1.6.3.56.9SECTION 435.217
     435.217 Individuals receiving home and community-based services.
42:4.0.1.1.6.3.56.10SECTION 435.218
     435.218 Individuals with MAGI-based income above 133 percent FPL.
42:4.0.1.1.6.3.56.11SECTION 435.219
     435.219 Individuals receiving State plan home and community-based services.
42:4.0.1.1.6.3.57SUBJGRP 57
  Options for Coverage of Families and Children
42:4.0.1.1.6.3.57.12SECTION 435.220
     435.220 Optional eligibility for parents and other caretaker relatives.
42:4.0.1.1.6.3.57.13SECTION 435.221
     435.221 [Reserved]
42:4.0.1.1.6.3.57.14SECTION 435.222
     435.222 Optional eligibility for reasonable classifications of individuals under age 21.
42:4.0.1.1.6.3.57.15SECTION 435.225
     435.225 Individuals under age 19 who would be eligible for Medicaid if they were in a medical institution.
42:4.0.1.1.6.3.57.16SECTION 435.226
     435.226 Optional eligibility for independent foster care adolescents.
42:4.0.1.1.6.3.57.17SECTION 435.227
     435.227 Optional eligibility for individuals under age 21 who are under State adoption assistance agreements.
42:4.0.1.1.6.3.57.18SECTION 435.229
     435.229 Optional targeted low-income children.
42:4.0.1.1.6.3.58SUBJGRP 58
  Options for Coverage of the Aged, Blind, and Disabled
42:4.0.1.1.6.3.58.19SECTION 435.230
     435.230 Aged, blind, and disabled individuals in States that use more restrictive requirements for Medicaid than SSI requirements: Optional coverage.
42:4.0.1.1.6.3.58.20SECTION 435.232
     435.232 Individuals receiving only optional State supplements.
42:4.0.1.1.6.3.58.21SECTION 435.234
     435.234 Individuals receiving only optional State supplements in States using more restrictive eligibility requirements than SSI and certain States using SSI criteria.
42:4.0.1.1.6.3.58.22SECTION 435.236
     435.236 Individuals in institutions who are eligible under a special income level.
42:4.0.1.1.6.4SUBPART D
Subpart D - Optional Coverage of the Medically Needy
42:4.0.1.1.6.4.59.1SECTION 435.300
     435.300 Scope.
42:4.0.1.1.6.4.59.2SECTION 435.301
     435.301 General rules.
42:4.0.1.1.6.4.59.3SECTION 435.308
     435.308 Medically needy coverage of individuals under age 21.
42:4.0.1.1.6.4.59.4SECTION 435.310
     435.310 Medically needy coverage of parents and other caretaker relatives.
42:4.0.1.1.6.4.59.5SECTION 435.320
     435.320 Medically needy coverage of the aged in States that cover individuals receiving SSI.
42:4.0.1.1.6.4.59.6SECTION 435.322
     435.322 Medically needy coverage of the blind in States that cover individuals receiving SSI.
42:4.0.1.1.6.4.59.7SECTION 435.324
     435.324 Medically needy coverage of the disabled in States that cover individuals receiving SSI.
42:4.0.1.1.6.4.59.8SECTION 435.326
     435.326 Individuals who would be ineligible if they were not enrolled in an MCO or PCCM.
42:4.0.1.1.6.4.59.9SECTION 435.330
     435.330 Medically needy coverage of the aged, blind, and disabled in States using more restrictive eligibility requirements for Medicaid than those used under SSI.
42:4.0.1.1.6.4.59.10SECTION 435.340
     435.340 Protected medically needy coverage for blind and disabled individuals eligible in December 1973.
42:4.0.1.1.6.4.59.11SECTION 435.350
     435.350 Coverage for certain aliens.
42:4.0.1.1.6.5SUBPART E
Subpart E - General Eligibility Requirements
42:4.0.1.1.6.5.59.1SECTION 435.400
     435.400 Scope.
42:4.0.1.1.6.5.59.2SECTION 435.401
     435.401 General rules.
42:4.0.1.1.6.5.59.3SECTION 435.402
     435.402 [Reserved]
42:4.0.1.1.6.5.59.4SECTION 435.403
     435.403 State residence.
42:4.0.1.1.6.5.59.5SECTION 435.404
     435.404 Applicant's choice of category.
42:4.0.1.1.6.5.59.6SECTION 435.406
     435.406 Citizenship and non-citizen eligibility.
42:4.0.1.1.6.5.59.7SECTION 435.407
     435.407 Types of acceptable documentary evidence of citizenship.
42:4.0.1.1.6.6SUBPART F
Subpart F - Categorical Requirements for Eligibility
42:4.0.1.1.6.6.59SUBJGRP 59
  Age
42:4.0.1.1.6.6.59.1SECTION 435.500
     435.500 Scope.
42:4.0.1.1.6.6.59.2SECTION 435.520
     435.520 Age requirements for the aged.
42:4.0.1.1.6.6.60SUBJGRP 60
  Blindness
42:4.0.1.1.6.6.60.3SECTION 435.530
     435.530 Definition of blindness.
42:4.0.1.1.6.6.60.4SECTION 435.531
     435.531 Determinations of blindness.
42:4.0.1.1.6.6.61SUBJGRP 61
  Disability
42:4.0.1.1.6.6.61.5SECTION 435.540
     435.540 Definition of disability.
42:4.0.1.1.6.6.61.6SECTION 435.541
     435.541 Determinations of disability.
42:4.0.1.1.6.7SUBPART G
Subpart G - General Financial Eligibility Requirements and Options
42:4.0.1.1.6.7.62.1SECTION 435.600
     435.600 Scope.
42:4.0.1.1.6.7.62.2SECTION 435.601
     435.601 Application of financial eligibility methodologies.
42:4.0.1.1.6.7.62.3SECTION 435.602
     435.602 Financial responsibility of relatives and other individuals.
42:4.0.1.1.6.7.62.4SECTION 435.603
     435.603 Application of modified adjusted gross income (MAGI).
42:4.0.1.1.6.7.62.5SECTION 435.604
     435.604 [Reserved]
42:4.0.1.1.6.7.62.6SECTION 435.606
     435.606 [Reserved]
42:4.0.1.1.6.7.62.7SECTION 435.608
     435.608 Applications for other benefits.
42:4.0.1.1.6.7.62.8SECTION 435.610
     435.610 Assignment of rights to benefits.
42:4.0.1.1.6.7.62.9SECTION 435.622
     435.622 Individuals in institutions who are eligible under a special income level.
42:4.0.1.1.6.7.62.10SECTION 435.631
     435.631 General requirements for determining income eligibility in States using more restrictive requirements for Medicaid than SSI.
42:4.0.1.1.6.7.62.11SECTION 435.640
     435.640 Protected Medicaid eligibility for individuals eligible in December 1973.
42:4.0.1.1.6.8SUBPART H
Subpart H - Specific Post-Eligibility Financial Requirements for the Categorically Needy
42:4.0.1.1.6.8.62.1SECTION 435.700
     435.700 Scope.
42:4.0.1.1.6.8.62.2SECTION 435.725
     435.725 Post-eligibility treatment of income of institutionalized individuals in SSI States: Application of patient income to the cost of care.
42:4.0.1.1.6.8.62.3SECTION 435.726
     435.726 Post-eligibility treatment of income of individuals receiving home and community-based services furnished under a waiver: Application of patient income to the cost of care.
42:4.0.1.1.6.8.62.4SECTION 435.733
     435.733 Post-eligibility treatment of income of institutionalized individuals in States using more restrictive requirements than SSI: Application of patient income to the cost of care.
42:4.0.1.1.6.8.62.5SECTION 435.735
     435.735 Post-eligibility treatment of income and resources of individuals receiving home and community-based services furnished under a waiver: Application of patient income to the cost of care.
42:4.0.1.1.6.9SUBPART I
Subpart I - Specific Eligibility and Post-Eligibility Financial Requirements for the Medically Needy
42:4.0.1.1.6.9.62SUBJGRP 62
  Medically Needy Income Standard
42:4.0.1.1.6.9.62.1SECTION 435.800
     435.800 Scope.
42:4.0.1.1.6.9.62.2SECTION 435.811
     435.811 Medically needy income standard: General requirements.
42:4.0.1.1.6.9.62.3SECTION 435.814
     435.814 Medically needy income standard: State plan requirements.
42:4.0.1.1.6.9.63SUBJGRP 63
  Medically Needy Income Eligibility
42:4.0.1.1.6.9.63.4SECTION 435.831
     435.831 Income eligibility.
42:4.0.1.1.6.9.63.5SECTION 435.832
     435.832 Post-eligibility treatment of income of institutionalized individuals: Application of patient income to the cost of care.
42:4.0.1.1.6.9.64SUBJGRP 64
  Medically Needy Resource Standard
42:4.0.1.1.6.9.64.6SECTION 435.840
     435.840 Medically needy resource standard: General requirements.
42:4.0.1.1.6.9.64.7SECTION 435.843
     435.843 Medically needy resource standard: State plan requirements.
42:4.0.1.1.6.9.65SUBJGRP 65
  Determining Eligibility on the Basis of Resources
42:4.0.1.1.6.9.65.8SECTION 435.845
     435.845 Medically needy resource eligibility.
42:4.0.1.1.6.9.65.9SECTION 435.850-435.852
     435.850-435.852 [Reserved]
42:4.0.1.1.6.10SUBPART J
Subpart J - Eligibility in the States and District of Columbia
42:4.0.1.1.6.10.66SUBJGRP 66
  General Methods of Administration
42:4.0.1.1.6.10.66.1SECTION 435.900
     435.900 Scope.
42:4.0.1.1.6.10.66.2SECTION 435.901
     435.901 Consistency with objectives and statutes.
42:4.0.1.1.6.10.66.3SECTION 435.902
     435.902 Simplicity of administration.
42:4.0.1.1.6.10.66.4SECTION 435.903
     435.903 Adherence of local agencies to State plan requirements.
42:4.0.1.1.6.10.66.5SECTION 435.904
     435.904 Establishment of outstation locations to process applications for certain low-income eligibility groups.
42:4.0.1.1.6.10.67SUBJGRP 67
  Applications
42:4.0.1.1.6.10.67.6SECTION 435.905
     435.905 Availability and accessibility of program information.
42:4.0.1.1.6.10.67.7SECTION 435.906
     435.906 Opportunity to apply.
42:4.0.1.1.6.10.67.8SECTION 435.907
     435.907 Application.
42:4.0.1.1.6.10.67.9SECTION 435.908
     435.908 Assistance with application and renewal.
42:4.0.1.1.6.10.67.10SECTION 435.909
     435.909 Automatic entitlement to Medicaid following a determination of eligibility under other programs.
42:4.0.1.1.6.10.67.11SECTION 435.910
     435.910 Use of social security number.
42:4.0.1.1.6.10.68SUBJGRP 68
  Determination of Medicaid Eligibility
42:4.0.1.1.6.10.68.12SECTION 435.911
     435.911 Determination of eligibility.
42:4.0.1.1.6.10.68.13SECTION 435.912
     435.912 Timely determination of eligibility.
42:4.0.1.1.6.10.68.14SECTION 435.914
     435.914 Case documentation.
42:4.0.1.1.6.10.68.15SECTION 435.915
     435.915 Effective date.
42:4.0.1.1.6.10.69SUBJGRP 69
  Redeterminations of Medicaid Eligibility
42:4.0.1.1.6.10.69.16SECTION 435.916
     435.916 Periodic renewal of Medicaid eligibility.
42:4.0.1.1.6.10.69.17SECTION 435.917
     435.917 Notice of agency's decision concerning eligibility, benefits, or services.
42:4.0.1.1.6.10.69.18SECTION 435.918
     435.918 Use of electronic notices.
42:4.0.1.1.6.10.69.19SECTION 435.920
     435.920 Verification of SSNs.
42:4.0.1.1.6.10.69.20SECTION 435.923
     435.923 Authorized representatives.
42:4.0.1.1.6.10.69.21SECTION 435.926
     435.926 Continuous eligibility for children.
42:4.0.1.1.6.10.70SUBJGRP 70
  Furnishing Medicaid
42:4.0.1.1.6.10.70.22SECTION 435.930
     435.930 Furnishing Medicaid.
42:4.0.1.1.6.10.71SUBJGRP 71
  Income and Eligibility Verification Requirements
42:4.0.1.1.6.10.71.23SECTION 435.940
     435.940 Basis and scope.
42:4.0.1.1.6.10.71.24SECTION 435.945
     435.945 General requirements.
42:4.0.1.1.6.10.71.25SECTION 435.948
     435.948 Verifying financial information.
42:4.0.1.1.6.10.71.26SECTION 435.949
     435.949 Verification of information through an electronic service.
42:4.0.1.1.6.10.71.27SECTION 435.952
     435.952 Use of information and requests of additional information from individuals.
42:4.0.1.1.6.10.71.28SECTION 435.956
     435.956 Verification of other non-financial information.
42:4.0.1.1.6.10.71.29SECTION 435.960
     435.960 Standardized formats for furnishing and obtaining information to verifying income and eligibility.
42:4.0.1.1.6.10.71.30SECTION 435.965
     435.965 Delay of effective date.
42:4.0.1.1.6.11SUBPART K
Subpart K - Federal Financial Participation
42:4.0.1.1.6.11.72SUBJGRP 72
  FFP in Expenditures for Determining Eligibility and Providing Services
42:4.0.1.1.6.11.72.1SECTION 435.1000
     435.1000 Scope.
42:4.0.1.1.6.11.72.2SECTION 435.1001
     435.1001 FFP for administration.
42:4.0.1.1.6.11.72.3SECTION 435.1002
     435.1002 FFP for services.
42:4.0.1.1.6.11.72.4SECTION 435.1003
     435.1003 FFP for redeterminations.
42:4.0.1.1.6.11.72.5SECTION 435.1004
     435.1004 Beneficiaries overcoming certain conditions of eligibility.
42:4.0.1.1.6.11.73SUBJGRP 73
  Limitations on FFP
42:4.0.1.1.6.11.73.6SECTION 435.1005
     435.1005 Beneficiaries in institutions eligible under a special income standard.
42:4.0.1.1.6.11.73.7SECTION 435.1006
     435.1006 Beneficiaries of optional State supplements only.
42:4.0.1.1.6.11.73.8SECTION 435.1007
     435.1007 Categorically needy, medically needy, and qualified Medicare beneficiaries.
42:4.0.1.1.6.11.73.9SECTION 435.1008
     435.1008 FFP in expenditures for medical assistance for individuals who have declared citizenship or nationality or satisfactory immigration status.
42:4.0.1.1.6.11.73.10SECTION 435.1009
     435.1009 Institutionalized individuals.
42:4.0.1.1.6.11.73.11SECTION 435.1010
     435.1010 Definitions relating to institutional status.
42:4.0.1.1.6.11.74SUBJGRP 74
  Requirements for State Supplements
42:4.0.1.1.6.11.74.12SECTION 435.1011
     435.1011 Requirement for mandatory State supplements.
42:4.0.1.1.6.11.74.13SECTION 435.1012
     435.1012 Requirement for maintenance of optional State supplement expenditures.
42:4.0.1.1.6.11.75SUBJGRP 75
  FFP for Premium Assistance
42:4.0.1.1.6.11.75.14SECTION 435.1015
     435.1015 FFP for premium assistance for plans in the individual market.
42:4.0.1.1.6.12SUBPART L
Subpart L - Options for Coverage of Special Groups under Presumptive Eligibility
42:4.0.1.1.6.12.76.1SECTION 435.1100
     435.1100 Basis for presumptive eligibility.
42:4.0.1.1.6.12.76.2SECTION 435.1101
     435.1101 Definitions related to presumptive eligibility.
42:4.0.1.1.6.12.76.3SECTION 435.1102
     435.1102 Children covered under presumptive eligibility.
42:4.0.1.1.6.12.76.4SECTION 435.1103
     435.1103 Presumptive eligibility for other individuals.
42:4.0.1.1.6.12.76.5SECTION 435.1110
     435.1110 Presumptive eligibility determined by hospitals.
42:4.0.1.1.6.13SUBPART M
Subpart M - Coordination of Eligibility and Enrollment Between Medicaid, CHIP, Exchanges and Other Insurance Affordability Programs
42:4.0.1.1.6.13.76.1SECTION 435.1200
     435.1200 Medicaid agency responsibilities for a coordinated eligibility and enrollment process with other insurance affordability programs.
42:4.0.1.1.6.13.76.2SECTION 435.1205
     435.1205 Alignment with exchange initial open enrollment period.
42:4.0.1.1.7PART 436
PART 436 - ELIGIBILITY IN GUAM, PUERTO RICO, AND THE VIRGIN ISLANDS
42:4.0.1.1.7.1SUBPART A
Subpart A - General Provisions and Definitions
42:4.0.1.1.7.1.88.1SECTION 436.1
     436.1 Purpose and applicability.
42:4.0.1.1.7.1.88.2SECTION 436.2
     436.2 Basis.
42:4.0.1.1.7.1.88.3SECTION 436.3
     436.3 Definitions and use of terms.
42:4.0.1.1.7.1.88.4SECTION 436.10
     436.10 State plan requirements.
42:4.0.1.1.7.2SUBPART B
Subpart B - Mandatory Coverage of the Categorically Needy
42:4.0.1.1.7.2.88.1SECTION 436.100
     436.100 Scope.
42:4.0.1.1.7.2.88.2SECTION 436.110
     436.110 Individuals receiving cash assistance.
42:4.0.1.1.7.2.88.3SECTION 436.111
     436.111 Individuals who are not eligible for cash assistance because of a requirement not applicable under Medicaid.
42:4.0.1.1.7.2.88.4SECTION 436.112
     436.112 Individuals who would be eligible for cash assistance except for increased OASDI under Pub. L. 92-336 (July 1, 1972).
42:4.0.1.1.7.2.88.5SECTION 436.114
     436.114 Individuals deemed to be receiving AFDC.
42:4.0.1.1.7.2.88.6SECTION 436.116
     436.116 Families terminated from AFDC because of increased earnings or hours of employment.
42:4.0.1.1.7.2.88.7SECTION 436.118
     436.118 Children for whom adoption assistance or foster care maintenance payments are made.
42:4.0.1.1.7.2.88.8SECTION 436.120
     436.120 Qualified pregnant women and children who are not qualified family members.
42:4.0.1.1.7.2.88.9SECTION 436.121
     436.121 Qualified family members.
42:4.0.1.1.7.2.88.10SECTION 436.122
     436.122 Pregnant women eligible for extended coverage.
42:4.0.1.1.7.2.88.11SECTION 436.124
     436.124 Newborn children.
42:4.0.1.1.7.2.88.12SECTION 436.128
     436.128 Coverage for certain qualified aliens.
42:4.0.1.1.7.3SUBPART C
Subpart C - Options for Coverage as Categorically Needy
42:4.0.1.1.7.3.88SUBJGRP 88
  Options for Coverage of Families and Children and Aged, Blind, and Disabled Individuals, Including Pregnant Women
42:4.0.1.1.7.3.88.1SECTION 436.200
     436.200 Scope.
42:4.0.1.1.7.3.88.2SECTION 436.201
     436.201 Individuals included in optional groups.
42:4.0.1.1.7.3.88.3SECTION 436.210
     436.210 Individuals who meet the income and resource requirements of the cash assistance programs.
42:4.0.1.1.7.3.88.4SECTION 436.211
     436.211 Individuals who would be eligible for cash assistance if they were not in medical institutions.
42:4.0.1.1.7.3.88.5SECTION 436.212
     436.212 Individuals who would be eligible for cash assistance if the State plan for OAA, AFDC, AB, APTD, or AABD were as broad as allowed under the Act.
42:4.0.1.1.7.3.88.6SECTION 436.217
     436.217 Individuals receiving home and community-based services.
42:4.0.1.1.7.3.88.7SECTION 436.219
     436.219 Individuals receiving State plan home and community-based services.
42:4.0.1.1.7.3.88.8SECTION 436.220
     436.220 Individuals who would meet the income and resource requirements under AFDC if child care costs were paid from earnings.
42:4.0.1.1.7.3.88.9SECTION 436.222
     436.222 Individuals under age 21 who meet the income and resource requirements of AFDC.
42:4.0.1.1.7.3.88.10SECTION 436.224
     436.224 Individuals under age 21 who are under State adoption assistance agreements.
42:4.0.1.1.7.3.88.11SECTION 436.229
     436.229 Optional targeted low-income children.
42:4.0.1.1.7.3.89SUBJGRP 89
  Options for Coverage of the Aged, Blind, and Disabled
42:4.0.1.1.7.3.89.12SECTION 436.230
     436.230 Essential spouses of aged, blind, or disabled individuals receiving cash assistance.
42:4.0.1.1.7.4SUBPART D
Subpart D - Optional Coverage of the Medically Needy
42:4.0.1.1.7.4.90.1SECTION 436.300
     436.300 Scope.
42:4.0.1.1.7.4.90.2SECTION 436.301
     436.301 General rules.
42:4.0.1.1.7.4.90.3SECTION 436.308
     436.308 Medically needy coverage of individuals under age 21.
42:4.0.1.1.7.4.90.4SECTION 436.310
     436.310 Medically needy coverage of specified relatives.
42:4.0.1.1.7.4.90.5SECTION 436.320
     436.320 Medically needy coverage of the aged.
42:4.0.1.1.7.4.90.6SECTION 436.321
     436.321 Medically needy coverage of the blind.
42:4.0.1.1.7.4.90.7SECTION 436.322
     436.322 Medically needy coverage of the disabled.
42:4.0.1.1.7.4.90.8SECTION 436.330
     436.330 Coverage for certain aliens.
42:4.0.1.1.7.5SUBPART E
Subpart E - General Eligibility Requirements
42:4.0.1.1.7.5.90.1SECTION 436.400
     436.400 Scope.
42:4.0.1.1.7.5.90.2SECTION 436.401
     436.401 General rules.
42:4.0.1.1.7.5.90.3SECTION 436.402
     436.402 [Reserved]
42:4.0.1.1.7.5.90.4SECTION 436.403
     436.403 State residence.
42:4.0.1.1.7.5.90.5SECTION 436.404
     436.404 Applicant's choice of category.
42:4.0.1.1.7.5.90.6SECTION 436.406
     436.406 Citizenship and alienage.
42:4.0.1.1.7.5.90.7SECTION 436.407
     436.407 Types of acceptable documentary evidence of citizenship.
42:4.0.1.1.7.5.90.8SECTION 436.408
     436.408 [Reserved]
42:4.0.1.1.7.6SUBPART F
Subpart F - Categorical Requirements for Medicaid Eligibility
42:4.0.1.1.7.6.90SUBJGRP 90
  Dependency
42:4.0.1.1.7.6.90.1SECTION 436.500
     436.500 Scope.
42:4.0.1.1.7.6.90.2SECTION 436.510
     436.510 Determination of dependency.
42:4.0.1.1.7.6.91SUBJGRP 91
  Age
42:4.0.1.1.7.6.91.3SECTION 436.520
     436.520 Age requirements for the aged.
42:4.0.1.1.7.6.91.4SECTION 436.522
     436.522 Determination of age.
42:4.0.1.1.7.6.92SUBJGRP 92
  Blindness
42:4.0.1.1.7.6.92.5SECTION 436.530
     436.530 Definition of blindness.
42:4.0.1.1.7.6.92.6SECTION 436.531
     436.531 Determination of blindness.
42:4.0.1.1.7.6.93SUBJGRP 93
  Disability
42:4.0.1.1.7.6.93.7SECTION 436.540
     436.540 Definition of disability.
42:4.0.1.1.7.6.93.8SECTION 436.541
     436.541 Determination of disability.
42:4.0.1.1.7.7SUBPART G
Subpart G - General Financial Eligibility Requirements and Options
42:4.0.1.1.7.7.94.1SECTION 436.600
     436.600 Scope.
42:4.0.1.1.7.7.94.2SECTION 436.601
     436.601 Application of financial eligibility methodologies.
42:4.0.1.1.7.7.94.3SECTION 436.602
     436.602 Financial responsibility of relatives and other individuals.
42:4.0.1.1.7.7.94.4SECTION 436.604
     436.604 [Reserved]
42:4.0.1.1.7.7.94.5SECTION 436.606
     436.606 [Reserved]
42:4.0.1.1.7.7.94.6SECTION 436.608
     436.608 Applications for other benefits.
42:4.0.1.1.7.7.94.7SECTION 436.610
     436.610 Assignment of rights to benefits.
42:4.0.1.1.7.8SUBPART H
Subpart H [Reserved]
42:4.0.1.1.7.9SUBPART I
Subpart I - Financial Requirements for the Medically Needy
42:4.0.1.1.7.9.94SUBJGRP 94
  Medically Needy Income Standard
42:4.0.1.1.7.9.94.1SECTION 436.800
     436.800 Scope.
42:4.0.1.1.7.9.94.2SECTION 436.811
     436.811 Medically needy income standard: General requirements.
42:4.0.1.1.7.9.94.3SECTION 436.814
     436.814 Medically needy income standard: State plan requirements.
42:4.0.1.1.7.9.95SUBJGRP 95
  Medically Needy Income Eligibility and Liability for Payment of Medical Expenses
42:4.0.1.1.7.9.95.4SECTION 436.831
     436.831 Income eligibility.
42:4.0.1.1.7.9.95.5SECTION 436.832
     436.832 Post-eligibility treatment of income of institutionalized individuals: Application of patient income to the cost of care.
42:4.0.1.1.7.9.96SUBJGRP 96
  Medically Needy Resource Standard
42:4.0.1.1.7.9.96.6SECTION 436.840
     436.840 Medically needy resource standard: General requirements.
42:4.0.1.1.7.9.96.7SECTION 436.843
     436.843 Medically needy resource standard: State plan requirements.
42:4.0.1.1.7.9.97SUBJGRP 97
  Determining Eligibility on the Basis of Resources
42:4.0.1.1.7.9.97.8SECTION 436.845
     436.845 Medically needy resource eligibility.
42:4.0.1.1.7.10SUBPART J
Subpart J - Eligibility in Guam, Puerto Rico, and the Virgin Islands
42:4.0.1.1.7.10.98.1SECTION 436.900
     436.900 Scope.
42:4.0.1.1.7.10.98.2SECTION 436.901
     436.901 General requirements.
42:4.0.1.1.7.10.98.3SECTION 436.909
     436.909 Automatic entitlement to Medicaid following a determination of eligibility under other programs.
42:4.0.1.1.7.11SUBPART K
Subpart K - Federal Financial Participation (FFP)
42:4.0.1.1.7.11.98SUBJGRP 98
  FFP for Expenditures for Determining Eligibility and Providing Services
42:4.0.1.1.7.11.98.1SECTION 436.1000
     436.1000 Scope.
42:4.0.1.1.7.11.98.2SECTION 436.1001
     436.1001 FFP for administration.
42:4.0.1.1.7.11.98.3SECTION 436.1002
     436.1002 FFP for services.
42:4.0.1.1.7.11.98.4SECTION 436.1003
     436.1003 beneficiaries overcoming certain conditions of eligibility.
42:4.0.1.1.7.11.98.5SECTION 436.1004
     436.1004 FFP in expenditures for medical assistance for individuals who have declared United States citizenship or nationality under section 1137(d) of the Act and with respect to whom the State has not documented citizenship and identity.
42:4.0.1.1.7.11.98.6SECTION 436.1005
     436.1005 Institutionalized individuals.
42:4.0.1.1.7.11.98.7SECTION 436.1006
     436.1006 Definitions relating to institutional status.
42:4.0.1.1.7.12SUBPART L
Subpart L - Option for Coverage of Special Groups
42:4.0.1.1.7.12.99SUBJGRP 99
  Presumptive Eligibility for Children
42:4.0.1.1.7.12.99.1SECTION 436.1100
     436.1100 Basis and scope.
42:4.0.1.1.7.12.99.2SECTION 436.1101
     436.1101 Definitions related to presumptive eligibility period for children.
42:4.0.1.1.7.12.99.3SECTION 436.1102
     436.1102 General rules.
42:4.0.1.1.8PART 438
PART 438 - MANAGED CARE
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.
42:4.0.1.1.9PART 440
PART 440 - SERVICES: GENERAL PROVISIONS
42:4.0.1.1.9.1SUBPART A
Subpart A - Definitions
42:4.0.1.1.9.1.100.1SECTION 440.1
     440.1 Basis and purpose.
42:4.0.1.1.9.1.100.2SECTION 440.2
     440.2 Specific definitions; definitions of services for FFP purposes.
42:4.0.1.1.9.1.100.3SECTION 440.10
     440.10 Inpatient hospital services, other than services in an institution for mental diseases.
42:4.0.1.1.9.1.100.4SECTION 440.20
     440.20 Outpatient hospital services and rural health clinic services.
42:4.0.1.1.9.1.100.5SECTION 440.30
     440.30 Other laboratory and X-ray services.
42:4.0.1.1.9.1.100.6SECTION 440.40
     440.40 Nursing facility services for individuals age 21 or older (other than services in an institution for mental disease), EPSDT, and family planning services and supplies.
42:4.0.1.1.9.1.100.7SECTION 440.50
     440.50 Physicians' services and medical and surgical services of a dentist.
42:4.0.1.1.9.1.100.8SECTION 440.60
     440.60 Medical or other remedial care provided by licensed practitioners.
42:4.0.1.1.9.1.100.9SECTION 440.70
     440.70 Home health services.
42:4.0.1.1.9.1.100.10SECTION 440.80
     440.80 Private duty nursing services.
42:4.0.1.1.9.1.100.11SECTION 440.90
     440.90 Clinic services.
42:4.0.1.1.9.1.100.12SECTION 440.100
     440.100 Dental services.
42:4.0.1.1.9.1.100.13SECTION 440.110
     440.110 Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders.
42:4.0.1.1.9.1.100.14SECTION 440.120
     440.120 Prescribed drugs, dentures, prosthetic devices, and eyeglasses.
42:4.0.1.1.9.1.100.15SECTION 440.130
     440.130 Diagnostic, screening, preventive, and rehabilitative services.
42:4.0.1.1.9.1.100.16SECTION 440.140
     440.140 Inpatient hospital services, nursing facility services, and intermediate care facility services for individuals age 65 or older in institutions for mental diseases.
42:4.0.1.1.9.1.100.17SECTION 440.150
     440.150 Intermediate care facility (ICF/IID) services.
42:4.0.1.1.9.1.100.18SECTION 440.155
     440.155 Nursing facility services, other than in institutions for mental diseases.
42:4.0.1.1.9.1.100.19SECTION 440.160
     440.160 Inpatient psychiatric services for individuals under age 21.
42:4.0.1.1.9.1.100.20SECTION 440.165
     440.165 Nurse-midwife service.
42:4.0.1.1.9.1.100.21SECTION 440.166
     440.166 Nurse practitioner services.
42:4.0.1.1.9.1.100.22SECTION 440.167
     440.167 Personal care services.
42:4.0.1.1.9.1.100.23SECTION 440.168
     440.168 Primary care case management services.
42:4.0.1.1.9.1.100.24SECTION 440.169
     440.169 Case management services.
42:4.0.1.1.9.1.100.25SECTION 440.170
     440.170 Any other medical care or remedial care recognized under State law and specified by the Secretary.
42:4.0.1.1.9.1.100.26SECTION 440.180
     440.180 Home and community-based waiver services.
42:4.0.1.1.9.1.100.27SECTION 440.181
     440.181 Home and community-based services for individuals age 65 or older.
42:4.0.1.1.9.1.100.28SECTION 440.182
     440.182 State plan home and community-based services.
42:4.0.1.1.9.1.100.29SECTION 440.185
     440.185 Respiratory care for ventilator-dependent individuals.
42:4.0.1.1.9.2SUBPART B
Subpart B - Requirements and Limits Applicable to All Services
42:4.0.1.1.9.2.100.1SECTION 440.200
     440.200 Basis, purpose, and scope.
42:4.0.1.1.9.2.100.2SECTION 440.210
     440.210 Required services for the categorically needy.
42:4.0.1.1.9.2.100.3SECTION 440.220
     440.220 Required services for the medically needy.
42:4.0.1.1.9.2.100.4SECTION 440.225
     440.225 Optional services.
42:4.0.1.1.9.2.100.5SECTION 440.230
     440.230 Sufficiency of amount, duration, and scope.
42:4.0.1.1.9.2.100.6SECTION 440.240
     440.240 Comparability of services for groups.
42:4.0.1.1.9.2.100.7SECTION 440.250
     440.250 Limits on comparability of services.
42:4.0.1.1.9.2.100.8SECTION 440.255
     440.255 Limited services available to certain aliens.
42:4.0.1.1.9.2.100.9SECTION 440.260
     440.260 Methods and standards to assure quality of services.
42:4.0.1.1.9.2.100.10SECTION 440.262
     440.262 Access and cultural considerations.
42:4.0.1.1.9.2.100.11SECTION 440.270
     440.270 Religious objections.
42:4.0.1.1.9.3SUBPART C
Subpart C - Benchmark Benefit and Benchmark-Equivalent Coverage
42:4.0.1.1.9.3.100.1SECTION 440.300
     440.300 Basis.
42:4.0.1.1.9.3.100.2SECTION 440.305
     440.305 Scope.
42:4.0.1.1.9.3.100.3SECTION 440.310
     440.310 Applicability.
42:4.0.1.1.9.3.100.4SECTION 440.315
     440.315 Exempt individuals.
42:4.0.1.1.9.3.100.5SECTION 440.320
     440.320 State plan requirements: Optional enrollment for exempt individuals.
42:4.0.1.1.9.3.100.6SECTION 440.325
     440.325 State plan requirements: Coverage and benefits.
42:4.0.1.1.9.3.100.7SECTION 440.330
     440.330 Benchmark health benefits coverage.
42:4.0.1.1.9.3.100.8SECTION 440.335
     440.335 Benchmark-equivalent health benefits coverage.
42:4.0.1.1.9.3.100.9SECTION 440.340
     440.340 Actuarial report for benchmark-equivalent coverage.
42:4.0.1.1.9.3.100.10SECTION 440.345
     440.345 EPSDT and other required benefits.
42:4.0.1.1.9.3.100.11SECTION 440.347
     440.347 Essential health benefits.
42:4.0.1.1.9.3.100.12SECTION 440.350
     440.350 Employer-sponsored insurance health plans.
42:4.0.1.1.9.3.100.13SECTION 440.355
     440.355 Payment of premiums.
42:4.0.1.1.9.3.100.14SECTION 440.360
     440.360 State plan requirements for providing additional services.
42:4.0.1.1.9.3.100.15SECTION 440.365
     440.365 Coverage of rural health clinic and federally qualified health center (FQHC) services.
42:4.0.1.1.9.3.100.16SECTION 440.370
     440.370 Economy and efficiency.
42:4.0.1.1.9.3.100.17SECTION 440.375
     440.375 Comparability.
42:4.0.1.1.9.3.100.18SECTION 440.380
     440.380 Statewideness.
42:4.0.1.1.9.3.100.19SECTION 440.385
     440.385 Delivery of benchmark and benchmark-equivalent coverage through managed care entities.
42:4.0.1.1.9.3.100.20SECTION 440.386
     440.386 Public notice.
42:4.0.1.1.9.3.100.21SECTION 440.390
     440.390 Assurance of transportation.
42:4.0.1.1.9.3.100.22SECTION 440.395
     440.395 Parity in mental health and substance use disorder benefits.
42:4.0.1.1.10PART 441
PART 441 - SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES
42:4.0.1.1.10.0.100.1SECTION 441.1
     441.1 Purpose.
42:4.0.1.1.10.1SUBPART A
Subpart A - General Provisions
42:4.0.1.1.10.1.100.1SECTION 441.10
     441.10 Basis.
42:4.0.1.1.10.1.100.2SECTION 441.11
     441.11 Continuation of FFP for institutional services.
42:4.0.1.1.10.1.100.3SECTION 441.12
     441.12 Inpatient hospital tests.
42:4.0.1.1.10.1.100.4SECTION 441.13
     441.13 Prohibitions on FFP: Institutionalized individuals.
42:4.0.1.1.10.1.100.5SECTION 441.15
     441.15 Home health services.
42:4.0.1.1.10.1.100.6SECTION 441.16
     441.16 Home health agency requirements for surety bonds; Prohibition on FFP.
42:4.0.1.1.10.1.100.7SECTION 441.17
     441.17 Laboratory services.
42:4.0.1.1.10.1.100.8SECTION 441.18
     441.18 Case management services.
42:4.0.1.1.10.1.100.9SECTION 441.20
     441.20 Family planning services.
42:4.0.1.1.10.1.100.10SECTION 441.21
     441.21 Nurse-midwife services.
42:4.0.1.1.10.1.100.11SECTION 441.22
     441.22 Nurse practitioner services.
42:4.0.1.1.10.1.100.12SECTION 441.25
     441.25 Prohibition on FFP for certain prescribed drugs.
42:4.0.1.1.10.1.100.13SECTION 441.30
     441.30 Optometric services.
42:4.0.1.1.10.1.100.14SECTION 441.35
     441.35 Organ transplants.
42:4.0.1.1.10.1.100.15SECTION 441.40
     441.40 End-stage renal disease.
42:4.0.1.1.10.2SUBPART B
Subpart B - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21
42:4.0.1.1.10.2.100.1SECTION 441.50
     441.50 Basis and purpose.
42:4.0.1.1.10.2.100.2SECTION 441.55
     441.55 State plan requirements.
42:4.0.1.1.10.2.100.3SECTION 441.56
     441.56 Required activities.
42:4.0.1.1.10.2.100.4SECTION 441.57
     441.57 Discretionary services.
42:4.0.1.1.10.2.100.5SECTION 441.58
     441.58 Periodicity schedule.
42:4.0.1.1.10.2.100.6SECTION 441.59
     441.59 Treatment of requests for EPSDT screening services.
42:4.0.1.1.10.2.100.7SECTION 441.60
     441.60 Continuing care.
42:4.0.1.1.10.2.100.8SECTION 441.61
     441.61 Utilization of providers and coordination with related programs.
42:4.0.1.1.10.2.100.9SECTION 441.62
     441.62 Transportation and scheduling assistance.
42:4.0.1.1.10.3SUBPART C
Subpart C - Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases
42:4.0.1.1.10.3.100.1SECTION 441.100
     441.100 Basis and purpose.
42:4.0.1.1.10.3.100.2SECTION 441.101
     441.101 State plan requirements.
42:4.0.1.1.10.3.100.3SECTION 441.102
     441.102 Plan of care for institutionalized beneficiaries.
42:4.0.1.1.10.3.100.4SECTION 441.103
     441.103 Alternate plans of care.
42:4.0.1.1.10.3.100.5SECTION 441.105
     441.105 Methods of administration.
42:4.0.1.1.10.3.100.6SECTION 441.106
     441.106 Comprehensive mental health program.
42:4.0.1.1.10.4SUBPART D
Subpart D - Inpatient Psychiatric Services for Individuals Under Age 21 in Psychiatric Facilities or Programs
42:4.0.1.1.10.4.100.1SECTION 441.150
     441.150 Basis and purpose.
42:4.0.1.1.10.4.100.2SECTION 441.151
     441.151 General requirements.
42:4.0.1.1.10.4.100.3SECTION 441.152
     441.152 Certification of need for services.
42:4.0.1.1.10.4.100.4SECTION 441.153
     441.153 Team certifying need for services.
42:4.0.1.1.10.4.100.5SECTION 441.154
     441.154 Active treatment.
42:4.0.1.1.10.4.100.6SECTION 441.155
     441.155 Individual plan of care.
42:4.0.1.1.10.4.100.7SECTION 441.156
     441.156 Team developing individual plan of care.
42:4.0.1.1.10.4.100.8SECTION 441.180
     441.180 Maintenance of effort: General rule.
42:4.0.1.1.10.4.100.9SECTION 441.181
     441.181 Maintenance of effort: Explanation of terms and requirements.
42:4.0.1.1.10.4.100.10SECTION 441.182
     441.182 Maintenance of effort: Computation.
42:4.0.1.1.10.4.100.11SECTION 441.184
     441.184 Emergency preparedness.
42:4.0.1.1.10.5SUBPART E
Subpart E - Abortions
42:4.0.1.1.10.5.100.1SECTION 441.200
     441.200 Basis and purpose.
42:4.0.1.1.10.5.100.2SECTION 441.201
     441.201 Definition.
42:4.0.1.1.10.5.100.3SECTION 441.202
     441.202 General rule.
42:4.0.1.1.10.5.100.4SECTION 441.203
     441.203 Life of the mother would be endangered.
42:4.0.1.1.10.5.100.5SECTION 441.204-441.205
     441.204-441.205 [Reserved]
42:4.0.1.1.10.5.100.6SECTION 441.206
     441.206 Documentation needed by the Medicaid agency.
42:4.0.1.1.10.5.100.7SECTION 441.207
     441.207 Drugs and devices and termination of ectopic pregnancies.
42:4.0.1.1.10.5.100.8SECTION 441.208
     441.208 Recordkeeping requirements.
42:4.0.1.1.10.6SUBPART F
Subpart F - Sterilizations
42:4.0.1.1.10.6.100.1SECTION 441.250
     441.250 Applicability.
42:4.0.1.1.10.6.100.2SECTION 441.251
     441.251 Definitions.
42:4.0.1.1.10.6.100.3SECTION 441.252
     441.252 State plan requirements.
42:4.0.1.1.10.6.100.4SECTION 441.253
     441.253 Sterilization of a mentally competent individual aged 21 or older.
42:4.0.1.1.10.6.100.5SECTION 441.254
     441.254 Mentally incompetent or institutionalized individuals.
42:4.0.1.1.10.6.100.6SECTION 441.255
     441.255 Sterilization by hysterectomy.
42:4.0.1.1.10.6.100.7SECTION 441.256
     441.256 Additional condition for Federal financial participation (FFP).
42:4.0.1.1.10.6.100.8SECTION 441.257
     441.257 Informed consent.
42:4.0.1.1.10.6.100.9SECTION 441.258
     441.258 Consent form requirements.
42:4.0.1.1.10.6.100.10SECTION 441.259
     441.259 Review of regulations.
42:4.0.1.1.10.6.100.11.1APPENDIX Appendix to
  Appendix to Subpart F of Part 441 - Required Consent Form
42:4.0.1.1.10.7SUBPART G
Subpart G - Home and Community-Based Services: Waiver Requirements
42:4.0.1.1.10.7.100.1SECTION 441.300
     441.300 Basis and purpose.
42:4.0.1.1.10.7.100.2SECTION 441.301
     441.301 Contents of request for a waiver.
42:4.0.1.1.10.7.100.3SECTION 441.302
     441.302 State assurances.
42:4.0.1.1.10.7.100.4SECTION 441.303
     441.303 Supporting documentation required.
42:4.0.1.1.10.7.100.5SECTION 441.304
     441.304 Duration, extension, and amendment of a waiver.
42:4.0.1.1.10.7.100.6SECTION 441.305
     441.305 Replacement of beneficiaries in approved waiver programs.
42:4.0.1.1.10.7.100.7SECTION 441.306
     441.306 Cooperative arrangements with the Maternal and Child Health program.
42:4.0.1.1.10.7.100.8SECTION 441.307
     441.307 Notification of a waiver termination.
42:4.0.1.1.10.7.100.9SECTION 441.308
     441.308 Hearings procedures for waiver terminations.
42:4.0.1.1.10.7.100.10SECTION 441.310
     441.310 Limits on Federal financial participation (FFP).
42:4.0.1.1.10.8SUBPART H
Subpart H - Home and Community-Based Services Waivers for Individuals Age 65 or Older: Waiver Requirements
42:4.0.1.1.10.8.100.1SECTION 441.350
     441.350 Basis and purpose.
42:4.0.1.1.10.8.100.2SECTION 441.351
     441.351 Contents of a request for a waiver.
42:4.0.1.1.10.8.100.3SECTION 441.352
     441.352 State assurances.
42:4.0.1.1.10.8.100.4SECTION 441.353
     441.353 Supporting documentation required.
42:4.0.1.1.10.8.100.5SECTION 441.354
     441.354 Aggregate projected expenditure limit (APEL).
42:4.0.1.1.10.8.100.6SECTION 441.355
     441.355 Duration, extension, and amendment of a waiver.
42:4.0.1.1.10.8.100.7SECTION 441.356
     441.356 Waiver termination.
42:4.0.1.1.10.8.100.8SECTION 441.357
     441.357 Hearing procedures for waiver denials.
42:4.0.1.1.10.8.100.9SECTION 441.360
     441.360 Limits on Federal financial participation (FFP).
42:4.0.1.1.10.8.100.10SECTION 441.365
     441.365 Periodic evaluation, assessment, and review.
42:4.0.1.1.10.9SUBPART I
Subpart I - Community Supported Living Arrangements Services
42:4.0.1.1.10.9.100.1SECTION 441.400
     441.400 Basis and purpose.
42:4.0.1.1.10.9.100.2SECTION 441.402
     441.402 State plan requirements.
42:4.0.1.1.10.9.100.3SECTION 441.404
     441.404 Minimum protection requirements.
42:4.0.1.1.10.10SUBPART J
Subpart J - Optional Self-Directed Personal Assistance Services Program
42:4.0.1.1.10.10.100.1SECTION 441.450
     441.450 Basis, scope, and definitions.
42:4.0.1.1.10.10.100.2SECTION 441.452
     441.452 Self-direction: General.
42:4.0.1.1.10.10.100.3SECTION 441.454
     441.454 Use of cash.
42:4.0.1.1.10.10.100.4SECTION 441.456
     441.456 Voluntary disenrollment.
42:4.0.1.1.10.10.100.5SECTION 441.458
     441.458 Involuntary disenrollment.
42:4.0.1.1.10.10.100.6SECTION 441.460
     441.460 Participant living arrangements.
42:4.0.1.1.10.10.100.7SECTION 441.462
     441.462 Statewideness, comparability and limitations on number served.
42:4.0.1.1.10.10.100.8SECTION 441.464
     441.464 State assurances.
42:4.0.1.1.10.10.100.9SECTION 441.466
     441.466 Assessment of need.
42:4.0.1.1.10.10.100.10SECTION 441.468
     441.468 Service plan elements.
42:4.0.1.1.10.10.100.11SECTION 441.470
     441.470 Service budget elements.
42:4.0.1.1.10.10.100.12SECTION 441.472
     441.472 Budget methodology.
42:4.0.1.1.10.10.100.13SECTION 441.474
     441.474 Quality assurance and improvement plan.
42:4.0.1.1.10.10.100.14SECTION 441.476
     441.476 Risk management.
42:4.0.1.1.10.10.100.15SECTION 441.478
     441.478 Qualifications of providers of personal assistance.
42:4.0.1.1.10.10.100.16SECTION 441.480
     441.480 Use of a representative.
42:4.0.1.1.10.10.100.17SECTION 441.482
     441.482 Permissible purchases.
42:4.0.1.1.10.10.100.18SECTION 441.484
     441.484 Financial management services.
42:4.0.1.1.10.11SUBPART K
Subpart K - Home and Community-Based Attendant Services and Supports State Plan Option (Community First Choice)
42:4.0.1.1.10.11.100.1SECTION 441.500
     441.500 Basis and scope.
42:4.0.1.1.10.11.100.2SECTION 441.505
     441.505 Definitions.
42:4.0.1.1.10.11.100.3SECTION 441.510
     441.510 Eligibility.
42:4.0.1.1.10.11.100.4SECTION 441.515
     441.515 Statewideness.
42:4.0.1.1.10.11.100.5SECTION 441.520
     441.520 Included services.
42:4.0.1.1.10.11.100.6SECTION 441.525
     441.525 Excluded services.
42:4.0.1.1.10.11.100.7SECTION 441.530
     441.530 Home and Community-Based Setting.
42:4.0.1.1.10.11.100.8SECTION 441.535
     441.535 Assessment of functional need.
42:4.0.1.1.10.11.100.9SECTION 441.540
     441.540 Person-centered service plan.
42:4.0.1.1.10.11.100.10SECTION 441.545
     441.545 Service models.
42:4.0.1.1.10.11.100.11SECTION 441.550
     441.550 Service plan requirements for self-directed model with service budget.
42:4.0.1.1.10.11.100.12SECTION 441.555
     441.555 Support system.
42:4.0.1.1.10.11.100.13SECTION 441.560
     441.560 Service budget requirements.
42:4.0.1.1.10.11.100.14SECTION 441.565
     441.565 Provider qualifications.
42:4.0.1.1.10.11.100.15SECTION 441.570
     441.570 State assurances.
42:4.0.1.1.10.11.100.16SECTION 441.575
     441.575 Development and Implementation Council.
42:4.0.1.1.10.11.100.17SECTION 441.580
     441.580 Data collection.
42:4.0.1.1.10.11.100.18SECTION 441.585
     441.585 Quality assurance system.
42:4.0.1.1.10.11.100.19SECTION 441.590
     441.590 Increased Federal financial participation.
42:4.0.1.1.10.12SUBPART L
Subpart L - Vaccines for Children Program
42:4.0.1.1.10.12.100.1SECTION 441.600
     441.600 Basis and purpose.
42:4.0.1.1.10.12.100.2SECTION 441.605
     441.605 General requirements.
42:4.0.1.1.10.12.100.3SECTION 441.610
     441.610 State plan requirements.
42:4.0.1.1.10.12.100.4SECTION 441.615
     441.615 Administration fee requirements.
42:4.0.1.1.10.13SUBPART M
Subpart M - State Plan Home and Community-Based Services for the Elderly and Individuals with Disabilities
42:4.0.1.1.10.13.100.1SECTION 441.700
     441.700 Basis and purpose.
42:4.0.1.1.10.13.100.2SECTION 441.705
     441.705 State plan requirements.
42:4.0.1.1.10.13.100.3SECTION 441.710
     441.710 State plan home and community-based services under section 1915(i)(1) of the Act.
42:4.0.1.1.10.13.100.4SECTION 441.715
     441.715 Needs-based criteria and evaluation.
42:4.0.1.1.10.13.100.5SECTION 441.720
     441.720 Independent assessment.
42:4.0.1.1.10.13.100.6SECTION 441.725
     441.725 Person-centered service plan.
42:4.0.1.1.10.13.100.7SECTION 441.730
     441.730 Provider qualifications.
42:4.0.1.1.10.13.100.8SECTION 441.735
     441.735 Definition of individual's representative.
42:4.0.1.1.10.13.100.9SECTION 441.740
     441.740 Self-directed services.
42:4.0.1.1.10.13.100.10SECTION 441.745
     441.745 State plan HCBS administration: State responsibilities and quality improvement.
42:4.0.1.1.11PART 442
PART 442 - STANDARDS FOR PAYMENT TO NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES
42:4.0.1.1.11.1SUBPART A
Subpart A - General Provisions
42:4.0.1.1.11.1.100.1SECTION 442.1
     442.1 Basis and purpose.
42:4.0.1.1.11.1.100.2SECTION 442.2
     442.2 Terms.
42:4.0.1.1.11.2SUBPART B
Subpart B - Provider Agreements
42:4.0.1.1.11.2.100.1SECTION 442.10
     442.10 State plan requirement.
42:4.0.1.1.11.2.100.2SECTION 442.12
     442.12 Provider agreement: General requirements.
42:4.0.1.1.11.2.100.3SECTION 442.13
     442.13 Effective date of provider agreement.
42:4.0.1.1.11.2.100.4SECTION 442.14
     442.14 Effect of change of ownership.
42:4.0.1.1.11.2.100.5SECTION 442.15
     442.15 Duration of agreement for ICF/IIDs.
42:4.0.1.1.11.2.100.6SECTION 442.16
     442.16 [Reserved]
42:4.0.1.1.11.2.100.7SECTION 442.30
     442.30 Agreement as evidence of certification.
42:4.0.1.1.11.2.100.8SECTION 442.40
     442.40 Availability of FFP during appeals for ICFs/IID.
42:4.0.1.1.11.2.100.9SECTION 442.42
     442.42 FFP under a retroactive provider agreement following appeal.
42:4.0.1.1.11.3SUBPART C
Subpart C - Certification of ICFs/IID
42:4.0.1.1.11.3.100.1SECTION 442.100
     442.100 State plan requirements.
42:4.0.1.1.11.3.100.2SECTION 442.101
     442.101 Obtaining certification.
42:4.0.1.1.11.3.100.3SECTION 442.105
     442.105 [Reserved]
42:4.0.1.1.11.3.100.4SECTION 442.109
     442.109 Certification period for ICF/IIDs: General provisions.
42:4.0.1.1.11.3.100.5SECTION 442.110
     442.110 Certification period for ICF/IID with standard-level deficiencies.
42:4.0.1.1.11.3.100.6SECTION 442.117
     442.117 Termination of certification for ICFs/IID whose deficiencies pose immediate jeopardy.
42:4.0.1.1.11.3.100.7SECTION 442.118
     442.118 Denial of payments for new admissions to an ICF/IID.
42:4.0.1.1.11.3.100.8SECTION 442.119
     442.119 Duration of denial of payments and subsequent termination of an ICF/IID.
42:4.0.1.1.11.4SUBPART D
Subparts D-F [Reserved]
42:4.0.1.1.12PART 447
PART 447 - PAYMENTS FOR SERVICES
42:4.0.1.1.12.1SUBPART A
Subpart A - Payments: General Provisions
42:4.0.1.1.12.1.109SUBJGRP 109
  Medicaid Premiums and Cost Sharing
42:4.0.1.1.12.1.109.1SECTION 447.1
     447.1 Purpose.
42:4.0.1.1.12.1.109.2SECTION 447.10
     447.10 Prohibition against reassignment of provider claims.
42:4.0.1.1.12.1.109.3SECTION 447.15
     447.15 Acceptance of State payment as payment in full.
42:4.0.1.1.12.1.109.4SECTION 447.20
     447.20 Provider restrictions: State plan requirements.
42:4.0.1.1.12.1.109.5SECTION 447.21
     447.21 Reduction of payments to providers.
42:4.0.1.1.12.1.109.6SECTION 447.25
     447.25 Direct payments to certain beneficiaries for physicians' or dentists' services.
42:4.0.1.1.12.1.109.7SECTION 447.26
     447.26 Prohibition on payment for provider-preventable conditions.
42:4.0.1.1.12.1.109.8SECTION 447.30
     447.30 Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments.
42:4.0.1.1.12.1.109.9SECTION 447.31
     447.31 Withholding Medicare payments to recover Medicaid overpayments.
42:4.0.1.1.12.1.109.10SECTION 447.40
     447.40 Payments for reserving beds in institutions.
42:4.0.1.1.12.1.109.11SECTION 447.45
     447.45 Timely claims payment.
42:4.0.1.1.12.1.109.12SECTION 447.46
     447.46 Timely claims payment by MCOs.
42:4.0.1.1.12.1.109.13SECTION 447.50
     447.50 Premiums and cost sharing: Basis and purpose.
42:4.0.1.1.12.1.109.14SECTION 447.51
     447.51 Definitions.
42:4.0.1.1.12.1.109.15SECTION 447.52
     447.52 Cost sharing.
42:4.0.1.1.12.1.109.16SECTION 447.53
     447.53 Cost sharing for drugs.
42:4.0.1.1.12.1.109.17SECTION 447.54
     447.54 Cost sharing for services furnished in a hospital emergency department.
42:4.0.1.1.12.1.109.18SECTION 447.55
     447.55 Premiums.
42:4.0.1.1.12.1.109.19SECTION 447.56
     447.56 Limitations on premiums and cost sharing.
42:4.0.1.1.12.1.109.20SECTION 447.57
     447.57 Beneficiary and public notice requirements.
42:4.0.1.1.12.1.109.21SECTION 447.88
     447.88 Options for claiming FFP payment for section 1920A presumptive eligibility medical assistance payments.
42:4.0.1.1.12.1.109.22SECTION 447.90
     447.90 FFP: Conditions related to pending investigations of credible allegations of fraud against the Medicaid program.
42:4.0.1.1.12.2SUBPART B
Subpart B - Payment Methods: General Provisions
42:4.0.1.1.12.2.110.1SECTION 447.200
     447.200 Basis and purpose.
42:4.0.1.1.12.2.110.2SECTION 447.201
     447.201 State plan requirements.
42:4.0.1.1.12.2.110.3SECTION 447.202
     447.202 Audits.
42:4.0.1.1.12.2.110.4SECTION 447.203
     447.203 Documentation of access to care and service payment rates.
42:4.0.1.1.12.2.110.5SECTION 447.204
     447.204 Medicaid provider participation and public process to inform access to care.
42:4.0.1.1.12.2.110.6SECTION 447.205
     447.205 Public notice of changes in Statewide methods and standards for setting payment rates.
42:4.0.1.1.12.3SUBPART C
Subpart C - Payment for Inpatient Hospital and Long-Term Care Facility Services
42:4.0.1.1.12.3.110SUBJGRP 110
  Payment Rates
42:4.0.1.1.12.3.110.1SECTION 447.250
     447.250 Basis and purpose.
42:4.0.1.1.12.3.110.2SECTION 447.251
     447.251 Definitions.
42:4.0.1.1.12.3.110.3SECTION 447.252
     447.252 State plan requirements.
42:4.0.1.1.12.3.110.4SECTION 447.253
     447.253 Other requirements.
42:4.0.1.1.12.3.110.5SECTION 447.255
     447.255 Related information.
42:4.0.1.1.12.3.110.6SECTION 447.256
     447.256 Procedures for CMS action on assurances and State plan amendments.
42:4.0.1.1.12.3.111SUBJGRP 111
  Federal Financial Participation
42:4.0.1.1.12.3.111.7SECTION 447.257
     447.257 FFP: Conditions relating to institutional reimbursement.
42:4.0.1.1.12.3.112SUBJGRP 112
  Upper Limits
42:4.0.1.1.12.3.112.8SECTION 447.271
     447.271 Upper limits based on customary charges.
42:4.0.1.1.12.3.112.9SECTION 447.272
     447.272 Inpatient services: Application of upper payment limits.
42:4.0.1.1.12.3.113SUBJGRP 113
  Swing-Bed Hospitals
42:4.0.1.1.12.3.113.10SECTION 447.280
     447.280 Hospital providers of NF services (swing-bed hospitals).
42:4.0.1.1.12.4SUBPART D
Subpart D [Reserved]
42:4.0.1.1.12.5SUBPART E
Subpart E - Payment Adjustments for Hospitals That Serve a Disproportionate Number of Low-Income Patients
42:4.0.1.1.12.5.114.1SECTION 447.294
     447.294 Medicaid disproportionate share hospital (DSH) allotment reductions.
42:4.0.1.1.12.5.114.2SECTION 447.295
     447.295 Hospital-specific disproportionate share hospital payment limit: Determination of individuals without health insurance or other third party coverage.
42:4.0.1.1.12.5.114.3SECTION 447.296
     447.296 Limitations on aggregate payments for disproportionate share hospitals for the period January 1, 1992 through September 30, 1992.
42:4.0.1.1.12.5.114.4SECTION 447.297
     447.297 Limitations on aggregate payments for disproportionate share hospitals beginning October 1, 1992.
42:4.0.1.1.12.5.114.5SECTION 447.298
     447.298 State disproportionate share hospital allotments.
42:4.0.1.1.12.5.114.6SECTION 447.299
     447.299 Reporting requirements.
42:4.0.1.1.12.6SUBPART F
Subpart F - Payment Methods for Other Institutional and Noninstitutional Services
42:4.0.1.1.12.6.114SUBJGRP 114
  Outpatient Hospital and Clinic Services
42:4.0.1.1.12.6.114.1SECTION 447.300
     447.300 Basis and purpose.
42:4.0.1.1.12.6.114.2SECTION 447.302
     447.302 State plan requirements.
42:4.0.1.1.12.6.114.3SECTION 447.304
     447.304 Adherence to upper limits; FFP.
42:4.0.1.1.12.6.114.4SECTION 447.321
     447.321 Outpatient hospital and clinic services: Application of upper payment limits.
42:4.0.1.1.12.6.115SUBJGRP 115
  Other Inpatient and Outpatient Facilities
42:4.0.1.1.12.6.115.5SECTION 447.325
     447.325 Other inpatient and outpatient facility services: Upper limits of payment.
42:4.0.1.1.12.6.115.6SECTION 447.342
     447.342 [Reserved]
42:4.0.1.1.12.6.116SUBJGRP 116
  Prepaid Capitation Plans
42:4.0.1.1.12.6.116.7SECTION 447.362
     447.362 Upper limits of payment: Nonrisk contract.
42:4.0.1.1.12.6.117SUBJGRP 117
  Rural Health Clinic Services
42:4.0.1.1.12.6.117.8SECTION 447.371
     447.371 Services furnished by rural health clinics.
42:4.0.1.1.12.7SUBPART G
Subpart G - Payments for Primary Care Services Furnished by Physicians
42:4.0.1.1.12.7.118.1SECTION 447.400
     447.400 Primary care services furnished by physicians with a specified specialty or subspecialty.
42:4.0.1.1.12.7.118.2SECTION 447.405
     447.405 Amount of required minimum payments.
42:4.0.1.1.12.7.118.3SECTION 447.410
     447.410 State plan requirements.
42:4.0.1.1.12.7.118.4SECTION 447.415
     447.415 Availability of Federal financial participation (FFP).
42:4.0.1.1.12.8SUBPART H
Subpart H [Reserved]
42:4.0.1.1.12.9SUBPART I
Subpart I - Payment for Drugs
42:4.0.1.1.12.9.118.1SECTION 447.500
     447.500 Basis and purpose.
42:4.0.1.1.12.9.118.2SECTION 447.502
     447.502 Definitions.
42:4.0.1.1.12.9.118.3SECTION 447.504
     447.504 Determination of average manufacturer price.
42:4.0.1.1.12.9.118.4SECTION 447.505
     447.505 Determination of best price.
42:4.0.1.1.12.9.118.5SECTION 447.506
     447.506 Authorized generic drugs.
42:4.0.1.1.12.9.118.6SECTION 447.507
     447.507 Identification of inhalation, infusion, instilled, implanted, or injectable drugs (5i drugs).
42:4.0.1.1.12.9.118.7SECTION 447.508
     447.508 Exclusion from best price of certain sales at a nominal price.
42:4.0.1.1.12.9.118.8SECTION 447.509
     447.509 Medicaid drug rebates (MDR).
42:4.0.1.1.12.9.118.9SECTION 447.510
     447.510 Requirements for manufacturers.
42:4.0.1.1.12.9.118.10SECTION 447.511
     447.511 Requirements for States.
42:4.0.1.1.12.9.118.11SECTION 447.512
     447.512 Drugs: Aggregate upper limits of payment.
42:4.0.1.1.12.9.118.12SECTION 447.514
     447.514 Upper limits for multiple source drugs.
42:4.0.1.1.12.9.118.13SECTION 447.516
     447.516 Upper limits for drugs furnished as part of services.
42:4.0.1.1.12.9.118.14SECTION 447.518
     447.518 State plan requirements, findings, and assurances.
42:4.0.1.1.12.9.118.15SECTION 447.520
     447.520 Federal Financial Participation (FFP): Conditions relating to physician-administered drugs.
42:4.0.1.1.12.9.118.16SECTION 447.522
     447.522 Optional coverage of investigational drugs and other drugs not subject to rebate.
42:4.0.1.1.13PART 455
PART 455 - PROGRAM INTEGRITY: MEDICAID
42:4.0.1.1.13.0.118.1SECTION 455.1
     455.1 Basis and scope.
42:4.0.1.1.13.0.118.2SECTION 455.2
     455.2 Definitions.
42:4.0.1.1.13.0.118.3SECTION 455.3
     455.3 Other applicable regulations.
42:4.0.1.1.13.1SUBPART A
Subpart A - Medicaid Agency Fraud Detection and Investigation Program
42:4.0.1.1.13.1.118.1SECTION 455.12
     455.12 State plan requirement.
42:4.0.1.1.13.1.118.2SECTION 455.13
     455.13 Methods for identification, investigation, and referral.
42:4.0.1.1.13.1.118.3SECTION 455.14
     455.14 Preliminary investigation.
42:4.0.1.1.13.1.118.4SECTION 455.15
     455.15 Full investigation.
42:4.0.1.1.13.1.118.5SECTION 455.16
     455.16 Resolution of full investigation.
42:4.0.1.1.13.1.118.6SECTION 455.17
     455.17 Reporting requirements.
42:4.0.1.1.13.1.118.7SECTION 455.18
     455.18 Provider's statements on claims forms.
42:4.0.1.1.13.1.118.8SECTION 455.19
     455.19 Provider's statement on check.
42:4.0.1.1.13.1.118.9SECTION 455.20
     455.20 Beneficiary verification procedure.
42:4.0.1.1.13.1.118.10SECTION 455.21
     455.21 Cooperation with State Medicaid fraud control units.
42:4.0.1.1.13.1.118.11SECTION 455.23
     455.23 Suspension of payments in cases of fraud.
42:4.0.1.1.13.2SUBPART B
Subpart B - Disclosure of Information by Providers and Fiscal Agents
42:4.0.1.1.13.2.118.1SECTION 455.100
     455.100 Purpose.
42:4.0.1.1.13.2.118.2SECTION 455.101
     455.101 Definitions.
42:4.0.1.1.13.2.118.3SECTION 455.102
     455.102 Determination of ownership or control percentages.
42:4.0.1.1.13.2.118.4SECTION 455.103
     455.103 State plan requirement.
42:4.0.1.1.13.2.118.5SECTION 455.104
     455.104 Disclosure by Medicaid providers and fiscal agents: Information on ownership and control.
42:4.0.1.1.13.2.118.6SECTION 455.105
     455.105 Disclosure by providers: Information related to business transactions.
42:4.0.1.1.13.2.118.7SECTION 455.106
     455.106 Disclosure by providers: Information on persons convicted of crimes.
42:4.0.1.1.13.2.118.8SECTION 455.107
     455.107 Disclosure of affiliations.
42:4.0.1.1.13.3SUBPART C
Subpart C - Medicaid Integrity Program
42:4.0.1.1.13.3.118.1SECTION 455.200
     455.200 Basis and scope.
42:4.0.1.1.13.3.118.2SECTION 455.202
     455.202 Limitation on contractor liability.
42:4.0.1.1.13.3.118.3SECTION 455.230
     455.230 Eligibility requirements.
42:4.0.1.1.13.3.118.4SECTION 455.232
     455.232 Medicaid integrity audit program contractor functions.
42:4.0.1.1.13.3.118.5SECTION 455.234
     455.234 Awarding of a contract.
42:4.0.1.1.13.3.118.6SECTION 455.236
     455.236 Renewal of a contract.
42:4.0.1.1.13.3.118.7SECTION 455.238
     455.238 Conflict of interest.
42:4.0.1.1.13.3.118.8SECTION 455.240
     455.240 Conflict of interest resolution.
42:4.0.1.1.13.4SUBPART D
Subpart D - Independent Certified Audit of State Disproportionate Share Hospital Payment Adjustments
42:4.0.1.1.13.4.118.1SECTION 455.300
     455.300 Purpose.
42:4.0.1.1.13.4.118.2SECTION 455.301
     455.301 Definitions.
42:4.0.1.1.13.4.118.3SECTION 455.304
     455.304 Condition for Federal financial participation (FFP).
42:4.0.1.1.13.5SUBPART E
Subpart E - Provider Screening and Enrollment
42:4.0.1.1.13.5.118.1SECTION 455.400
     455.400 Purpose.
42:4.0.1.1.13.5.118.2SECTION 455.405
     455.405 State plan requirements.
42:4.0.1.1.13.5.118.3SECTION 455.410
     455.410 Enrollment and screening of providers.
42:4.0.1.1.13.5.118.4SECTION 455.412
     455.412 Verification of provider licenses.
42:4.0.1.1.13.5.118.5SECTION 455.414
     455.414 Revalidation of enrollment.
42:4.0.1.1.13.5.118.6SECTION 455.416
     455.416 Termination or denial of enrollment.
42:4.0.1.1.13.5.118.7SECTION 455.420
     455.420 Reactivation of provider enrollment.
42:4.0.1.1.13.5.118.8SECTION 455.422
     455.422 Appeal rights.
42:4.0.1.1.13.5.118.9SECTION 455.432
     455.432 Site visits.
42:4.0.1.1.13.5.118.10SECTION 455.434
     455.434 Criminal background checks.
42:4.0.1.1.13.5.118.11SECTION 455.436
     455.436 Federal database checks.
42:4.0.1.1.13.5.118.12SECTION 455.440
     455.440 National Provider Identifier.
42:4.0.1.1.13.5.118.13SECTION 455.450
     455.450 Screening levels for Medicaid providers.
42:4.0.1.1.13.5.118.14SECTION 455.452
     455.452 Other State screening methods.
42:4.0.1.1.13.5.118.15SECTION 455.460
     455.460 Application fee.
42:4.0.1.1.13.5.118.16SECTION 455.470
     455.470 Temporary moratoria.
42:4.0.1.1.13.6SUBPART F
Subpart F - Medicaid Recovery Audit Contractors Program
42:4.0.1.1.13.6.118.1SECTION 455.500
     455.500 Purpose.
42:4.0.1.1.13.6.118.2SECTION 455.502
     455.502 Establishment of program.
42:4.0.1.1.13.6.118.3SECTION 455.504
     455.504 Definitions.
42:4.0.1.1.13.6.118.4SECTION 455.506
     455.506 Activities to be conducted by Medicaid RACs and States.
42:4.0.1.1.13.6.118.5SECTION 455.508
     455.508 Eligibility requirements for Medicaid RACs.
42:4.0.1.1.13.6.118.6SECTION 455.510
     455.510 Payments to RACs.
42:4.0.1.1.13.6.118.7SECTION 455.512
     455.512 Medicaid RAC provider appeals.
42:4.0.1.1.13.6.118.8SECTION 455.514
     455.514 Federal share of State expense of the Medicaid RAC program.
42:4.0.1.1.13.6.118.9SECTION 455.516
     455.516 Exceptions from Medicaid RAC programs.
42:4.0.1.1.13.6.118.10SECTION 455.518
     455.518 Applicability to the territories.
42:4.0.1.1.14PART 456
PART 456 - UTILIZATION CONTROL
42:4.0.1.1.14.1SUBPART A
Subpart A - General Provisions
42:4.0.1.1.14.1.143.1SECTION 456.1
     456.1 Basis and purpose of part.
42:4.0.1.1.14.1.143.2SECTION 456.2
     456.2 State plan requirements.
42:4.0.1.1.14.1.143.3SECTION 456.3
     456.3 Statewide surveillance and utilization control program.
42:4.0.1.1.14.1.143.4SECTION 456.4
     456.4 Responsibility for monitoring the utilization control program.
42:4.0.1.1.14.1.143.5SECTION 456.5
     456.5 Evaluation criteria.
42:4.0.1.1.14.1.143.6SECTION 456.6
     456.6 Review by State medical agency of appropriateness and quality of services.
42:4.0.1.1.14.2SUBPART B
Subpart B - Utilization Control: All Medicaid Services
42:4.0.1.1.14.2.143.1SECTION 456.21
     456.21 Scope.
42:4.0.1.1.14.2.143.2SECTION 456.22
     456.22 Sample basis evaluation of services.
42:4.0.1.1.14.2.143.3SECTION 456.23
     456.23 Post-payment review process.
42:4.0.1.1.14.3SUBPART C
Subpart C - Utilization Control: Hospitals
42:4.0.1.1.14.3.143SUBJGRP 143
  Certification of Need for Care
42:4.0.1.1.14.3.143.1SECTION 456.50
     456.50 Scope.
42:4.0.1.1.14.3.143.2SECTION 456.51
     456.51 Definitions.
42:4.0.1.1.14.3.143.3SECTION 456.60
     456.60 Certification and recertification of need for inpatient care.
42:4.0.1.1.14.3.144SUBJGRP 144
  Plan of Care
42:4.0.1.1.14.3.144.4SECTION 456.80
     456.80 Individual written plan of care.
42:4.0.1.1.14.3.145SUBJGRP 145
  Utilization Review (UR) Plan: General Requirement
42:4.0.1.1.14.3.145.5SECTION 456.100
     456.100 Scope.
42:4.0.1.1.14.3.145.6SECTION 456.101
     456.101 UR plan required for inpatient hospital services.
42:4.0.1.1.14.3.146SUBJGRP 146
  UR Plan: Administrative Requirements
42:4.0.1.1.14.3.146.7SECTION 456.105
     456.105 UR committee required.
42:4.0.1.1.14.3.146.8SECTION 456.106
     456.106 Organization and composition of UR committee; disqualification from UR committee membership.
42:4.0.1.1.14.3.147SUBJGRP 147
  UR Plan: Informational Requirements
42:4.0.1.1.14.3.147.9SECTION 456.111
     456.111 Beneficiary information required for UR.
42:4.0.1.1.14.3.147.10SECTION 456.112
     456.112 Records and reports.
42:4.0.1.1.14.3.147.11SECTION 456.113
     456.113 Confidentiality.
42:4.0.1.1.14.3.148SUBJGRP 148
  UR Plan: Review of Need for Admission 1 />
42:4.0.1.1.14.3.148.12SECTION 456.121
     456.121 Admission review required.
42:4.0.1.1.14.3.148.13SECTION 456.122
     456.122 Evaluation criteria for admission review.
42:4.0.1.1.14.3.148.14SECTION 456.123
     456.123 Admission review process.
42:4.0.1.1.14.3.148.15SECTION 456.124
     456.124 Notification of adverse decision.
42:4.0.1.1.14.3.148.16SECTION 456.125
     456.125 Time limits for admission review.
42:4.0.1.1.14.3.148.17SECTION 456.126
     456.126 Time limits for final decision and notification of adverse decision.
42:4.0.1.1.14.3.148.18SECTION 456.127
     456.127 Pre-admission review.
42:4.0.1.1.14.3.148.19SECTION 456.128
     456.128 Initial continued stay review date.
42:4.0.1.1.14.3.148.20SECTION 456.129
     456.129 Description of methods and criteria: Initial continued stay review date; close professional scrutiny; length of stay modification.
42:4.0.1.1.14.3.149SUBJGRP 149
  UR Plan: Review of Need for Continued Stay
42:4.0.1.1.14.3.149.21SECTION 456.131
     456.131 Continued stay review required.
42:4.0.1.1.14.3.149.22SECTION 456.132
     456.132 Evaluation criteria for continued stay.
42:4.0.1.1.14.3.149.23SECTION 456.133
     456.133 Subsequent continued stay review dates.
42:4.0.1.1.14.3.149.24SECTION 456.134
     456.134 Description of methods and criteria: Subsequent continued stay review dates; length of stay modification.
42:4.0.1.1.14.3.149.25SECTION 456.135
     456.135 Continued stay review process.
42:4.0.1.1.14.3.149.26SECTION 456.136
     456.136 Notification of adverse decision.
42:4.0.1.1.14.3.149.27SECTION 456.137
     456.137 Time limits for final decision and notification of adverse decision.
42:4.0.1.1.14.3.150SUBJGRP 150
  UR Plan: Medical Care Evaluation Studies
42:4.0.1.1.14.3.150.28SECTION 456.141
     456.141 Purpose and general description.
42:4.0.1.1.14.3.150.29SECTION 456.142
     456.142 UR plan requirements for medical care evaluation studies.
42:4.0.1.1.14.3.150.30SECTION 456.143
     456.143 Content of medical care evaluation studies.
42:4.0.1.1.14.3.150.31SECTION 456.144
     456.144 Data sources for studies.
42:4.0.1.1.14.3.150.32SECTION 456.145
     456.145 Number of studies required to be performed.
42:4.0.1.1.14.4SUBPART D
Subpart D - Utilization Control: Mental Hospitals
42:4.0.1.1.14.4.151SUBJGRP 151
  Certification of Need for Care
42:4.0.1.1.14.4.151.1SECTION 456.150
     456.150 Scope.
42:4.0.1.1.14.4.151.2SECTION 456.151
     456.151 Definitions.
42:4.0.1.1.14.4.151.3SECTION 456.160
     456.160 Certification and recertification of need for inpatient care.
42:4.0.1.1.14.4.152SUBJGRP 152
  Medical, Psychiatric, and Social Evaluations and Admission Review
42:4.0.1.1.14.4.152.4SECTION 456.170
     456.170 Medical, psychiatric, and social evaluations.
42:4.0.1.1.14.4.152.5SECTION 456.171
     456.171 [Reserved]
42:4.0.1.1.14.4.153SUBJGRP 153
  Plan of Care
42:4.0.1.1.14.4.153.6SECTION 456.180
     456.180 Individual written plan of care.
42:4.0.1.1.14.4.153.7SECTION 456.181
     456.181 Reports of evaluations and plans of care.
42:4.0.1.1.14.4.154SUBJGRP 154
  Utilization Review (UR) Plan: General Requirements
42:4.0.1.1.14.4.154.8SECTION 456.200
     456.200 Scope.
42:4.0.1.1.14.4.154.9SECTION 456.201
     456.201 UR plan required for inpatient mental hospital services.
42:4.0.1.1.14.4.155SUBJGRP 155
  UR Plan: Administrative Requirements
42:4.0.1.1.14.4.155.10SECTION 456.205
     456.205 UR committee required.
42:4.0.1.1.14.4.155.11SECTION 456.206
     456.206 Organization and composition of UR committee; disqualification from UR committee membership.
42:4.0.1.1.14.4.156SUBJGRP 156
  UR Plan: Informational Requirements
42:4.0.1.1.14.4.156.12SECTION 456.211
     456.211 Beneficiary information required for UR.
42:4.0.1.1.14.4.156.13SECTION 456.212
     456.212 Records and reports.
42:4.0.1.1.14.4.156.14SECTION 456.213
     456.213 Confidentiality.
42:4.0.1.1.14.4.157SUBJGRP 157
  UR Plan: Review of Need for Continued Stay
42:4.0.1.1.14.4.157.15SECTION 456.231
     456.231 Continued stay review required.
42:4.0.1.1.14.4.157.16SECTION 456.232
     456.232 Evaluation criteria for continued stay.
42:4.0.1.1.14.4.157.17SECTION 456.233
     456.233 Initial continued stay review date.
42:4.0.1.1.14.4.157.18SECTION 456.234
     456.234 Subsequent continued stay review dates.
42:4.0.1.1.14.4.157.19SECTION 456.235
     456.235 Description of methods and criteria: Continued stay review dates; length of stay modification.
42:4.0.1.1.14.4.157.20SECTION 456.236
     456.236 Continued stay review process.
42:4.0.1.1.14.4.157.21SECTION 456.237
     456.237 Notification of adverse decision.
42:4.0.1.1.14.4.157.22SECTION 456.238
     456.238 Time limits for final decision and notification of adverse decision.
42:4.0.1.1.14.4.158SUBJGRP 158
  UR Plan: Medical Care Evaluation Studies
42:4.0.1.1.14.4.158.23SECTION 456.241
     456.241 Purpose and general description.
42:4.0.1.1.14.4.158.24SECTION 456.242
     456.242 UR plan requirements for medical care evaluation studies.
42:4.0.1.1.14.4.158.25SECTION 456.243
     456.243 Content of medical care evaluation studies.
42:4.0.1.1.14.4.158.26SECTION 456.244
     456.244 Data sources for studies.
42:4.0.1.1.14.4.158.27SECTION 456.245
     456.245 Number of studies required to be performed.
42:4.0.1.1.14.5SUBPART E
Subpart E [Reserved]
42:4.0.1.1.14.6SUBPART F
Subpart F - Utilization Control: Intermediate Care Facilities
42:4.0.1.1.14.6.159SUBJGRP 159
  Certification of Need for Care
42:4.0.1.1.14.6.159.1SECTION 456.350
     456.350 Scope.
42:4.0.1.1.14.6.159.2SECTION 456.351
     456.351 Definition.
42:4.0.1.1.14.6.159.3SECTION 456.360
     456.360 Certification and recertification of need for inpatient care.
42:4.0.1.1.14.6.160SUBJGRP 160
  Medical, Psychological, and Social Evaluations and Admission Review
42:4.0.1.1.14.6.160.4SECTION 456.370
     456.370 Medical, psychological, and social evaluations.
42:4.0.1.1.14.6.160.5SECTION 456.371
     456.371 Exploration of alternative services.
42:4.0.1.1.14.6.160.6SECTION 456.372
     456.372 Medicaid agency review of need for admission.
42:4.0.1.1.14.6.161SUBJGRP 161
  Plan of Care
42:4.0.1.1.14.6.161.7SECTION 456.380
     456.380 Individual written plan of care.
42:4.0.1.1.14.6.161.8SECTION 456.381
     456.381 Reports of evaluations and plans of care.
42:4.0.1.1.14.6.162SUBJGRP 162
  Utilization Review (UR) Plan: General Requirement
42:4.0.1.1.14.6.162.9SECTION 456.400
     456.400 Scope.
42:4.0.1.1.14.6.162.10SECTION 456.401
     456.401 State plan UR requirements and options; UR plan required for intermediate care facility services.
42:4.0.1.1.14.6.163SUBJGRP 163
  UR Plan: Administrative Requirements
42:4.0.1.1.14.6.163.11SECTION 456.405
     456.405 Description of UR review function: How and when.
42:4.0.1.1.14.6.163.12SECTION 456.406
     456.406 Description of UR review function: Who performs UR; disqualification from performing UR.
42:4.0.1.1.14.6.163.13SECTION 456.407
     456.407 UR responsibilities of administrative staff.
42:4.0.1.1.14.6.164SUBJGRP 164
  UR Plan: Informational Requirements
42:4.0.1.1.14.6.164.14SECTION 456.411
     456.411 Beneficiary information required for UR.
42:4.0.1.1.14.6.164.15SECTION 456.412
     456.412 Records and reports.
42:4.0.1.1.14.6.164.16SECTION 456.413
     456.413 Confidentiality.
42:4.0.1.1.14.6.165SUBJGRP 165
  UR Plan: Review of Need for Continued Stay
42:4.0.1.1.14.6.165.17SECTION 456.431
     456.431 Continued stay review required.
42:4.0.1.1.14.6.165.18SECTION 456.432
     456.432 Evaluation criteria for continued stay.
42:4.0.1.1.14.6.165.19SECTION 456.433
     456.433 Initial continued stay review date.
42:4.0.1.1.14.6.165.20SECTION 456.434
     456.434 Subsequent continued stay review dates.
42:4.0.1.1.14.6.165.21SECTION 456.435
     456.435 Description of methods and criteria: Continued stay review dates.
42:4.0.1.1.14.6.165.22SECTION 456.436
     456.436 Continued stay review process.
42:4.0.1.1.14.6.165.23SECTION 456.437
     456.437 Notification of adverse decision.
42:4.0.1.1.14.6.165.24SECTION 456.438
     456.438 Time limits for notification of adverse decision.
42:4.0.1.1.14.7SUBPART G
Subpart G - Inpatient Psychiatric Services for Individuals Under Age 21: Admission and Plan of Care Requirements
42:4.0.1.1.14.7.166.1SECTION 456.480
     456.480 Scope.
42:4.0.1.1.14.7.166.2SECTION 456.481
     456.481 Admission certification and plan of care.
42:4.0.1.1.14.7.166.3SECTION 456.482
     456.482 Medical, psychiatric, and social evaluations.
42:4.0.1.1.14.8SUBPART H
Subpart H - Utilization Review Plans: FFP, Waivers, and Variances for Hospitals and Mental Hospitals
42:4.0.1.1.14.8.166SUBJGRP 166
  UR Plan: Waiver of Requirements
42:4.0.1.1.14.8.166.1SECTION 456.500
     456.500 Purpose.
42:4.0.1.1.14.8.166.2SECTION 456.501
     456.501 UR plans as a condition for FFP.
42:4.0.1.1.14.8.166.3SECTION 456.505
     456.505 Applicability of waiver.
42:4.0.1.1.14.8.166.4SECTION 456.506
     456.506 Waiver options for Medicaid agency.
42:4.0.1.1.14.8.166.5SECTION 456.507
     456.507 Review and granting of waiver requests.
42:4.0.1.1.14.8.166.6SECTION 456.508
     456.508 Withdrawal of waiver.
42:4.0.1.1.14.8.167SUBJGRP 167
  UR Plan: Remote Facility Variances from Time Requirements
42:4.0.1.1.14.8.167.7SECTION 456.520
     456.520 Definitions.
42:4.0.1.1.14.8.167.8SECTION 456.521
     456.521 Conditions for granting variance requests.
42:4.0.1.1.14.8.167.9SECTION 456.522
     456.522 Content of request for variance.
42:4.0.1.1.14.8.167.10SECTION 456.523
     456.523 Revised UR plan.
42:4.0.1.1.14.8.167.11SECTION 456.524
     456.524 Notification of Administrator's action and duration of variance.
42:4.0.1.1.14.8.167.12SECTION 456.525
     456.525 Request for renewal of variance.
42:4.0.1.1.14.9SUBPART I
Subpart I - Inspections of Care in Intermediate Care Facilities and Institutions for Mental Diseases
42:4.0.1.1.14.9.168.1SECTION 456.600
     456.600 Purpose.
42:4.0.1.1.14.9.168.2SECTION 456.601
     456.601 Definitions.
42:4.0.1.1.14.9.168.3SECTION 456.602
     456.602 Inspection team.
42:4.0.1.1.14.9.168.4SECTION 456.603
     456.603 Financial interests and employment of team members.
42:4.0.1.1.14.9.168.5SECTION 456.604
     456.604 Physician team member inspecting care of beneficiaries.
42:4.0.1.1.14.9.168.6SECTION 456.605
     456.605 Number and location of teams.
42:4.0.1.1.14.9.168.7SECTION 456.606
     456.606 Frequency of inspections.
42:4.0.1.1.14.9.168.8SECTION 456.607
     456.607 Notification before inspection.
42:4.0.1.1.14.9.168.9SECTION 456.608
     456.608 Personal contact with and observation of beneficiaries and review of records.
42:4.0.1.1.14.9.168.10SECTION 456.609
     456.609 Determinations by team.
42:4.0.1.1.14.9.168.11SECTION 456.610
     456.610 Basis for determinations.
42:4.0.1.1.14.9.168.12SECTION 456.611
     456.611 Reports on inspections.
42:4.0.1.1.14.9.168.13SECTION 456.612
     456.612 Copies of reports.
42:4.0.1.1.14.9.168.14SECTION 456.613
     456.613 Action on reports.
42:4.0.1.1.14.9.168.15SECTION 456.614
     456.614 Inspections by utilization review committee.
42:4.0.1.1.14.10SUBPART J
Subpart J - Penalty for Failure To Make a Satisfactory Showing of an Effective Institutional Utilization Control Program
42:4.0.1.1.14.10.168.1SECTION 456.650
     456.650 Basis, purpose and scope.
42:4.0.1.1.14.10.168.2SECTION 456.651
     456.651 Definitions.
42:4.0.1.1.14.10.168.3SECTION 456.652
     456.652 Requirements for an effective utilization control program.
42:4.0.1.1.14.10.168.4SECTION 456.653
     456.653 Acceptable reasons for not meeting requirements for annual on-site review.
42:4.0.1.1.14.10.168.5SECTION 456.654
     456.654 Requirements for content of showings and procedures for submittal.
42:4.0.1.1.14.10.168.6SECTION 456.655
     456.655 Validation of showings.
42:4.0.1.1.14.10.168.7SECTION 456.656
     456.656 Reductions in FFP.
42:4.0.1.1.14.10.168.8SECTION 456.657
     456.657 Computation of reductions in FFP.
42:4.0.1.1.14.11SUBPART K
Subpart K - Drug Use Review (DUR) Program and Electronic Claims Management System for Outpatient Drug Claims
42:4.0.1.1.14.11.168.1SECTION 456.700
     456.700 Scope.
42:4.0.1.1.14.11.168.2SECTION 456.702
     456.702 Definitions.
42:4.0.1.1.14.11.168.3SECTION 456.703
     456.703 Drug use review program.
42:4.0.1.1.14.11.168.4SECTION 456.705
     456.705 Prospective drug review.
42:4.0.1.1.14.11.168.5SECTION 456.709
     456.709 Retrospective drug use review.
42:4.0.1.1.14.11.168.6SECTION 456.711
     456.711 Educational program.
42:4.0.1.1.14.11.168.7SECTION 456.712
     456.712 Annual report.
42:4.0.1.1.14.11.168.8SECTION 456.714
     456.714 DUR/surveillance and utilization review relationship.
42:4.0.1.1.14.11.168.9SECTION 456.716
     456.716 DUR Board.
42:4.0.1.1.14.11.168.10SECTION 456.719
     456.719 Funding for DUR program.
42:4.0.1.1.14.11.168.11SECTION 456.722
     456.722 Electronic claims management system.
42:4.0.1.1.14.11.168.12SECTION 456.725
     456.725 Funding of ECM system.