| 42:4.0.1.1.1 | PART 430
| PART 430 - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS | |
| 42:4.0.1.1.1.1 | SUBPART A
| Subpart A - Introduction; General Provisions | |
| 42:4.0.1.1.1.1.1.1 | SECTION 430.0
| 430.0 Program description. | |
| 42:4.0.1.1.1.1.1.2 | SECTION 430.1
| 430.1 Scope of subchapter C. | |
| 42:4.0.1.1.1.1.1.3 | SECTION 430.2
| 430.2 Other applicable Federal regulations. | |
| 42:4.0.1.1.1.1.1.4 | SECTION 430.3
| 430.3 Appeals under Medicaid. | |
| 42:4.0.1.1.1.1.1.5 | SECTION 430.5
| 430.5 Definitions. | |
| 42:4.0.1.1.1.2 | SUBPART B
| Subpart B - State Plans | |
| 42:4.0.1.1.1.2.1.1 | SECTION 430.10
| 430.10 The State plan. | |
| 42:4.0.1.1.1.2.1.2 | SECTION 430.12
| 430.12 Submittal of State plans and plan amendments. | |
| 42:4.0.1.1.1.2.1.3 | SECTION 430.14
| 430.14 Review of State plan material. | |
| 42:4.0.1.1.1.2.1.4 | SECTION 430.15
| 430.15 Basis and authority for action on State plan material. | |
| 42:4.0.1.1.1.2.1.5 | SECTION 430.16
| 430.16 Timing and notice of action on State plan material. | |
| 42:4.0.1.1.1.2.1.6 | SECTION 430.18
| 430.18 Administrative review of action on State plan material. | |
| 42:4.0.1.1.1.2.1.7 | SECTION 430.20
| 430.20 Effective dates of State plans and plan amendments. | |
| 42:4.0.1.1.1.2.1.8 | SECTION 430.25
| 430.25 Waivers of State plan requirements. | |
| 42:4.0.1.1.1.3 | SUBPART C
| Subpart C - Grants; Reviews and Audits; Withholding for Failure To Comply; Deferral and Disallowance of Claims; Reduction of Federal Medicaid Payments | |
| 42:4.0.1.1.1.3.1.1 | SECTION 430.30
| 430.30 Grants procedures. | |
| 42:4.0.1.1.1.3.1.2 | SECTION 430.32
| 430.32 Program reviews. | |
| 42:4.0.1.1.1.3.1.3 | SECTION 430.33
| 430.33 Audits. | |
| 42:4.0.1.1.1.3.1.4 | SECTION 430.35
| 430.35 Withholding of payment for failure to comply with Federal requirements. | |
| 42:4.0.1.1.1.3.1.5 | SECTION 430.38
| 430.38 Judicial review. | |
| 42:4.0.1.1.1.3.1.6 | SECTION 430.40
| 430.40 Deferral of claims for FFP. | |
| 42:4.0.1.1.1.3.1.7 | SECTION 430.42
| 430.42 Disallowance of claims for FFP. | |
| 42:4.0.1.1.1.3.1.8 | SECTION 430.45
| 430.45 Reduction of Federal Medicaid payments. | |
| 42:4.0.1.1.1.3.1.9 | SECTION 430.48
| 430.48 Repayment of Federal funds by installments. | |
| 42:4.0.1.1.1.4 | SUBPART D
| Subpart D - Hearings on Conformity of State Medicaid Plans and Practice to Federal Requirements | |
| 42:4.0.1.1.1.4.1.1 | SECTION 430.60
| 430.60 Scope. | |
| 42:4.0.1.1.1.4.1.2 | SECTION 430.62
| 430.62 Records to be public. | |
| 42:4.0.1.1.1.4.1.3 | SECTION 430.63
| 430.63 Filing and service of papers. | |
| 42:4.0.1.1.1.4.1.4 | SECTION 430.64
| 430.64 Suspension of rules. | |
| 42:4.0.1.1.1.4.1.5 | SECTION 430.66
| 430.66 Designation of presiding officer for hearing. | |
| 42:4.0.1.1.1.4.1.6 | SECTION 430.70
| 430.70 Notice of hearing or opportunity for hearing. | |
| 42:4.0.1.1.1.4.1.7 | SECTION 430.72
| 430.72 Time and place of hearing. | |
| 42:4.0.1.1.1.4.1.8 | SECTION 430.74
| 430.74 Issues at hearing. | |
| 42:4.0.1.1.1.4.1.9 | SECTION 430.76
| 430.76 Parties to the hearing. | |
| 42:4.0.1.1.1.4.1.10 | SECTION 430.80
| 430.80 Authority of the presiding officer. | |
| 42:4.0.1.1.1.4.1.11 | SECTION 430.83
| 430.83 Rights of parties. | |
| 42:4.0.1.1.1.4.1.12 | SECTION 430.86
| 430.86 Discovery. | |
| 42:4.0.1.1.1.4.1.13 | SECTION 430.88
| 430.88 Evidence. | |
| 42:4.0.1.1.1.4.1.14 | SECTION 430.90
| 430.90 Exclusion from hearing for misconduct. | |
| 42:4.0.1.1.1.4.1.15 | SECTION 430.92
| 430.92 Unsponsored written material. | |
| 42:4.0.1.1.1.4.1.16 | SECTION 430.94
| 430.94 Official transcript. | |
| 42:4.0.1.1.1.4.1.17 | SECTION 430.96
| 430.96 Record for decision. | |
| 42:4.0.1.1.1.4.1.18 | SECTION 430.100
| 430.100 Posthearing briefs. | |
| 42:4.0.1.1.1.4.1.19 | SECTION 430.102
| 430.102 Decisions following hearing. | |
| 42:4.0.1.1.1.4.1.20 | SECTION 430.104
| 430.104 Decisions that affect FFP. | |
| 42:4.0.1.1.2 | PART 431
| PART 431 - STATE ORGANIZATION AND GENERAL ADMINISTRATION | |
| 42:4.0.1.1.2.0.8.1 | SECTION 431.1
| 431.1 Purpose. | |
| 42:4.0.1.1.2.1 | SUBPART A
| Subpart A - Single State Agency | |
| 42:4.0.1.1.2.1.8.1 | SECTION 431.10
| 431.10 Single State agency. | |
| 42:4.0.1.1.2.1.8.2 | SECTION 431.11
| 431.11 Organization for administration. | |
| 42:4.0.1.1.2.1.8.3 | SECTION 431.12
| 431.12 Medical care advisory committee. | |
| 42:4.0.1.1.2.1.8.4 | SECTION 431.15
| 431.15 Methods of administration. | |
| 42:4.0.1.1.2.1.8.5 | SECTION 431.16
| 431.16 Reports. | |
| 42:4.0.1.1.2.1.8.6 | SECTION 431.17
| 431.17 Maintenance of records. | |
| 42:4.0.1.1.2.1.8.7 | SECTION 431.18
| 431.18 Availability of agency program manuals. | |
| 42:4.0.1.1.2.1.8.8 | SECTION 431.20
| 431.20 Advance directives. | |
| 42:4.0.1.1.2.2 | SUBPART B
| Subpart B - General Administrative Requirements | |
| 42:4.0.1.1.2.2.8.1 | SECTION 431.40
| 431.40 Basis and scope. | |
| 42:4.0.1.1.2.2.8.2 | SECTION 431.50
| 431.50 Statewide operation. | |
| 42:4.0.1.1.2.2.8.3 | SECTION 431.51
| 431.51 Free choice of providers. | |
| 42:4.0.1.1.2.2.8.4 | SECTION 431.52
| 431.52 Payments for services furnished out of State. | |
| 42:4.0.1.1.2.2.8.5 | SECTION 431.53
| 431.53 Assurance of transportation. | |
| 42:4.0.1.1.2.2.8.6 | SECTION 431.54
| 431.54 Exceptions to certain State plan requirements. | |
| 42:4.0.1.1.2.2.8.7 | SECTION 431.55
| 431.55 Waiver of other Medicaid requirements. | |
| 42:4.0.1.1.2.2.8.8 | SECTION 431.56
| 431.56 Special waiver provisions applicable to American Samoa and the Northern Mariana Islands. | |
| 42:4.0.1.1.2.2.8.9 | SECTION 431.60
| 431.60 Beneficiary access to and exchange of data. | |
| 42:4.0.1.1.2.2.8.10 | SECTION 431.70
| 431.70 Access to published provider directory information. | |
| 42:4.0.1.1.2.3 | SUBPART C
| Subpart C - Administrative Requirements: Provider Relations | |
| 42:4.0.1.1.2.3.8.1 | SECTION 431.105
| 431.105 Consultation to medical facilities. | |
| 42:4.0.1.1.2.3.8.2 | SECTION 431.107
| 431.107 Required provider agreement. | |
| 42:4.0.1.1.2.3.8.3 | SECTION 431.108
| 431.108 Effective date of provider agreements. | |
| 42:4.0.1.1.2.3.8.4 | SECTION 431.110
| 431.110 Participation by Indian Health Service facilities. | |
| 42:4.0.1.1.2.3.8.5 | SECTION 431.115
| 431.115 Disclosure of survey information and provider or contractor evaluation. | |
| 42:4.0.1.1.2.3.8.6 | SECTION 431.120
| 431.120 State requirements with respect to nursing facilities. | |
| 42:4.0.1.1.2.4 | SUBPART D
| Subpart D - Appeals Process for NFs and ICFs/IID | |
| 42:4.0.1.1.2.4.8.1 | SECTION 431.151
| 431.151 Scope and applicability. | |
| 42:4.0.1.1.2.4.8.2 | SECTION 431.152
| 431.152 State plan requirements. | |
| 42:4.0.1.1.2.4.8.3 | SECTION 431.153
| 431.153 Evidentiary hearing. | |
| 42:4.0.1.1.2.4.8.4 | SECTION 431.154
| 431.154 Informal reconsideration for ICFs/IID. | |
| 42:4.0.1.1.2.5 | SUBPART E
| Subpart E - Fair Hearings for Applicants and Beneficiaries | |
| 42:4.0.1.1.2.5.8 | SUBJGRP 8
| General Provisions | |
| 42:4.0.1.1.2.5.8.1 | SECTION 431.200
| 431.200 Basis and scope. | |
| 42:4.0.1.1.2.5.8.2 | SECTION 431.201
| 431.201 Definitions. | |
| 42:4.0.1.1.2.5.8.3 | SECTION 431.202
| 431.202 State plan requirements. | |
| 42:4.0.1.1.2.5.8.4 | SECTION 431.205
| 431.205 Provision of hearing system. | |
| 42:4.0.1.1.2.5.8.5 | SECTION 431.206
| 431.206 Informing applicants and beneficiaries. | |
| 42:4.0.1.1.2.5.9 | SUBJGRP 9
| Notice | |
| 42:4.0.1.1.2.5.9.6 | SECTION 431.210
| 431.210 Content of notice. | |
| 42:4.0.1.1.2.5.9.7 | SECTION 431.211
| 431.211 Advance notice. | |
| 42:4.0.1.1.2.5.9.8 | SECTION 431.213
| 431.213 Exceptions from advance notice. | |
| 42:4.0.1.1.2.5.9.9 | SECTION 431.214
| 431.214 Notice in cases of probable fraud. | |
| 42:4.0.1.1.2.5.10 | SUBJGRP 10
| Right to Hearing | |
| 42:4.0.1.1.2.5.10.10 | SECTION 431.220
| 431.220 When a hearing is required. | |
| 42:4.0.1.1.2.5.10.11 | SECTION 431.221
| 431.221 Request for hearing. | |
| 42:4.0.1.1.2.5.10.12 | SECTION 431.222
| 431.222 Group hearings. | |
| 42:4.0.1.1.2.5.10.13 | SECTION 431.223
| 431.223 Denial or dismissal of request for a hearing. | |
| 42:4.0.1.1.2.5.10.14 | SECTION 431.224
| 431.224 Expedited appeals. | |
| 42:4.0.1.1.2.5.11 | SUBJGRP 11
| Procedures | |
| 42:4.0.1.1.2.5.11.15 | SECTION 431.230
| 431.230 Maintaining services. | |
| 42:4.0.1.1.2.5.11.16 | SECTION 431.231
| 431.231 Reinstating services. | |
| 42:4.0.1.1.2.5.11.17 | SECTION 431.232
| 431.232 Adverse decision of local evidentiary hearing. | |
| 42:4.0.1.1.2.5.11.18 | SECTION 431.233
| 431.233 State agency hearing after adverse decision of local evidentiary hearing. | |
| 42:4.0.1.1.2.5.11.19 | SECTION 431.240
| 431.240 Conducting the hearing. | |
| 42:4.0.1.1.2.5.11.20 | SECTION 431.241
| 431.241 Matters to be considered at the hearing. | |
| 42:4.0.1.1.2.5.11.21 | SECTION 431.242
| 431.242 Procedural rights of the applicant or beneficiary. | |
| 42:4.0.1.1.2.5.11.22 | SECTION 431.243
| 431.243 Parties in cases involving an eligibility determination. | |
| 42:4.0.1.1.2.5.11.23 | SECTION 431.244
| 431.244 Hearing decisions. | |
| 42:4.0.1.1.2.5.11.24 | SECTION 431.245
| 431.245 Notifying the applicant or beneficiary of a State agency decision. | |
| 42:4.0.1.1.2.5.11.25 | SECTION 431.246
| 431.246 Corrective action. | |
| 42:4.0.1.1.2.5.12 | SUBJGRP 12
| Federal Financial Participation | |
| 42:4.0.1.1.2.5.12.26 | SECTION 431.250
| 431.250 Federal financial participation. | |
| 42:4.0.1.1.2.6 | SUBPART F
| Subpart F - Safeguarding Information on Applicants and Beneficiaries | |
| 42:4.0.1.1.2.6.13.1 | SECTION 431.300
| 431.300 Basis and purpose. | |
| 42:4.0.1.1.2.6.13.2 | SECTION 431.301
| 431.301 State plan requirements. | |
| 42:4.0.1.1.2.6.13.3 | SECTION 431.302
| 431.302 Purposes directly related to State plan administration. | |
| 42:4.0.1.1.2.6.13.4 | SECTION 431.303
| 431.303 State authority for safeguarding information. | |
| 42:4.0.1.1.2.6.13.5 | SECTION 431.304
| 431.304 Publicizing safeguarding requirements. | |
| 42:4.0.1.1.2.6.13.6 | SECTION 431.305
| 431.305 Types of information to be safeguarded. | |
| 42:4.0.1.1.2.6.13.7 | SECTION 431.306
| 431.306 Release of information. | |
| 42:4.0.1.1.2.6.13.8 | SECTION 431.307
| 431.307 Distribution of information materials. | |
| 42:4.0.1.1.2.7 | SUBPART G
| Subpart G - Section 1115 Demonstrations | |
| 42:4.0.1.1.2.7.13.1 | SECTION 431.400
| 431.400 Basis and purpose. | |
| 42:4.0.1.1.2.7.13.2 | SECTION 431.404
| 431.404 Definitions. | |
| 42:4.0.1.1.2.7.13.3 | SECTION 431.408
| 431.408 State public notice process. | |
| 42:4.0.1.1.2.7.13.4 | SECTION 431.412
| 431.412 Application procedures. | |
| 42:4.0.1.1.2.7.13.5 | SECTION 431.416
| 431.416 Federal public notice and approval process. | |
| 42:4.0.1.1.2.7.13.6 | SECTION 431.420
| 431.420 Monitoring and compliance. | |
| 42:4.0.1.1.2.7.13.7 | SECTION 431.424
| 431.424 Evaluation requirements. | |
| 42:4.0.1.1.2.7.13.8 | SECTION 431.428
| 431.428 Reporting requirements. | |
| 42:4.0.1.1.2.8 | SUBPART H
| Subparts H-L [Reserved] | |
| 42:4.0.1.1.2.9 | SUBPART M
| Subpart M - Relations With Other Agencies | |
| 42:4.0.1.1.2.9.13.1 | SECTION 431.610
| 431.610 Relations with standard-setting and survey agencies. | |
| 42:4.0.1.1.2.9.13.2 | SECTION 431.615
| 431.615 Relations with State health and vocational rehabilitation agencies and title V grantees. | |
| 42:4.0.1.1.2.9.13.3 | SECTION 431.620
| 431.620 Agreement with State mental health authority or mental institutions. | |
| 42:4.0.1.1.2.9.13.4 | SECTION 431.621
| 431.621 State requirements with respect to nursing facilities. | |
| 42:4.0.1.1.2.9.13.5 | SECTION 431.625
| 431.625 Coordination of Medicaid with Medicare part B. | |
| 42:4.0.1.1.2.9.13.6 | SECTION 431.630
| 431.630 Coordination of Medicaid with QIOs. | |
| 42:4.0.1.1.2.9.13.7 | SECTION 431.635
| 431.635 Coordination of Medicaid with Special Supplemental Food Program for Women, Infants, and Children (WIC). | |
| 42:4.0.1.1.2.10 | SUBPART N
| Subpart N - State Programs for Licensing Nursing Home Administrators | |
| 42:4.0.1.1.2.10.13.1 | SECTION 431.700
| 431.700 Basis and purpose. | |
| 42:4.0.1.1.2.10.13.2 | SECTION 431.701
| 431.701 Definitions. | |
| 42:4.0.1.1.2.10.13.3 | SECTION 431.702
| 431.702 State plan requirement. | |
| 42:4.0.1.1.2.10.13.4 | SECTION 431.703
| 431.703 Licensing requirement. | |
| 42:4.0.1.1.2.10.13.5 | SECTION 431.704
| 431.704 Nursing homes designated by other terms. | |
| 42:4.0.1.1.2.10.13.6 | SECTION 431.705
| 431.705 Licensing authority. | |
| 42:4.0.1.1.2.10.13.7 | SECTION 431.706
| 431.706 Composition of licensing board. | |
| 42:4.0.1.1.2.10.13.8 | SECTION 431.707
| 431.707 Standards. | |
| 42:4.0.1.1.2.10.13.9 | SECTION 431.708
| 431.708 Procedures for applying standards. | |
| 42:4.0.1.1.2.10.13.10 | SECTION 431.709
| 431.709 Issuance and revocation of license. | |
| 42:4.0.1.1.2.10.13.11 | SECTION 431.710
| 431.710 Provisional licenses. | |
| 42:4.0.1.1.2.10.13.12 | SECTION 431.711
| 431.711 Compliance with standards. | |
| 42:4.0.1.1.2.10.13.13 | SECTION 431.712
| 431.712 Failure to comply with standards. | |
| 42:4.0.1.1.2.10.13.14 | SECTION 431.713
| 431.713 Continuing study and investigation. | |
| 42:4.0.1.1.2.10.13.15 | SECTION 431.714
| 431.714 Waivers. | |
| 42:4.0.1.1.2.10.13.16 | SECTION 431.715
| 431.715 Federal financial participation. | |
| 42:4.0.1.1.2.11 | SUBPART O
| Subpart O [Reserved] | |
| 42:4.0.1.1.2.12 | SUBPART P
| Subpart P - Quality Control | |
| 42:4.0.1.1.2.12.13 | SUBJGRP 13
| Medicaid Eligibility Quality Control (MEQC) Program | |
| 42:4.0.1.1.2.12.13.1 | SECTION 431.800
| 431.800 Basis and scope. | |
| 42:4.0.1.1.2.12.13.2 | SECTION 431.804
| 431.804 Definitions. | |
| 42:4.0.1.1.2.12.13.3 | SECTION 431.806
| 431.806 State requirements. | |
| 42:4.0.1.1.2.12.13.4 | SECTION 431.808
| 431.808 Protection of beneficiary rights. | |
| 42:4.0.1.1.2.12.13.5 | SECTION 431.810
| 431.810 Basic elements of the Medicaid Eligibility Quality Control (MEQC) Program. | |
| 42:4.0.1.1.2.12.13.6 | SECTION 431.812
| 431.812 Review procedures. | |
| 42:4.0.1.1.2.12.13.7 | SECTION 431.814
| 431.814 Pilot planning document. | |
| 42:4.0.1.1.2.12.13.8 | SECTION 431.816
| 431.816 Case review completion deadlines and submittal of reports. | |
| 42:4.0.1.1.2.12.13.9 | SECTION 431.818
| 431.818 Access to records. | |
| 42:4.0.1.1.2.12.13.10 | SECTION 431.820
| 431.820 Corrective action under the MEQC program. | |
| 42:4.0.1.1.2.12.14 | SUBJGRP 14
| Medicaid Quality Control (MQC) Claims Processing Assessment System | |
| 42:4.0.1.1.2.12.14.11 | SECTION 431.830
| 431.830 Basic elements of the Medicaid quality control (MQC) claims processing assessment system. | |
| 42:4.0.1.1.2.12.14.12 | SECTION 431.832
| 431.832 Reporting requirements for claims processing assessment systems. | |
| 42:4.0.1.1.2.12.14.13 | SECTION 431.834
| 431.834 Access to records: Claims processing assessment systems. | |
| 42:4.0.1.1.2.12.14.14 | SECTION 431.836
| 431.836 Corrective action under the MQC claims processing assessment system. | |
| 42:4.0.1.1.2.13 | SUBPART Q
| Subpart Q - Requirements for Estimating Improper Payments in Medicaid and CHIP | |
| 42:4.0.1.1.2.13.15.1 | SECTION 431.950
| 431.950 Purpose. | |
| 42:4.0.1.1.2.13.15.2 | SECTION 431.954
| 431.954 Basis and scope. | |
| 42:4.0.1.1.2.13.15.3 | SECTION 431.958
| 431.958 Definitions and use of terms. | |
| 42:4.0.1.1.2.13.15.4 | SECTION 431.960
| 431.960 Types of payment errors. | |
| 42:4.0.1.1.2.13.15.5 | SECTION 431.970
| 431.970 Information submission and systems access requirements. | |
| 42:4.0.1.1.2.13.15.6 | SECTION 431.972
| 431.972 Claims sampling procedures. | |
| 42:4.0.1.1.2.13.15.7 | SECTION 431.992
| 431.992 Corrective action plan. | |
| 42:4.0.1.1.2.13.15.8 | SECTION 431.998
| 431.998 Difference resolution and appeal process. | |
| 42:4.0.1.1.2.13.15.9 | SECTION 431.1002
| 431.1002 Recoveries. | |
| 42:4.0.1.1.2.13.15.10 | SECTION 431.1010
| 431.1010 Disallowance of Federal financial participation for erroneous State payments (for PERM review years ending after July 1, 2020). | |
| 42:4.0.1.1.3 | PART 432
| PART 432 - STATE PERSONNEL ADMINISTRATION | |
| 42:4.0.1.1.3.1 | SUBPART A
| Subpart A - General Provisions | |
| 42:4.0.1.1.3.1.15.1 | SECTION 432.1
| 432.1 Basis and purpose. | |
| 42:4.0.1.1.3.1.15.2 | SECTION 432.2
| 432.2 Definitions. | |
| 42:4.0.1.1.3.1.15.3 | SECTION 432.10
| 432.10 Standards of personnel administration. | |
| 42:4.0.1.1.3.2 | SUBPART B
| Subpart B - Training Programs; Subprofessional and Volunteer Programs | |
| 42:4.0.1.1.3.2.15.1 | SECTION 432.30
| 432.30 Training programs: General requirements. | |
| 42:4.0.1.1.3.2.15.2 | SECTION 432.31
| 432.31 Training and use of subprofessional staff. | |
| 42:4.0.1.1.3.2.15.3 | SECTION 432.32
| 432.32 Training and use of volunteers. | |
| 42:4.0.1.1.3.3 | SUBPART C
| Subpart C - Staffing and Training Expenditures | |
| 42:4.0.1.1.3.3.15.1 | SECTION 432.45
| 432.45 Applicability of provisions in subpart. | |
| 42:4.0.1.1.3.3.15.2 | SECTION 432.50
| 432.50 FFP: Staffing and training costs. | |
| 42:4.0.1.1.3.3.15.3 | SECTION 432.55
| 432.55 Reporting training and administrative costs. | |
| 42:4.0.1.1.4 | PART 433
| PART 433 - STATE FISCAL ADMINISTRATION | |
| 42:4.0.1.1.4.0.17.1 | SECTION 433.1
| 433.1 Purpose. | |
| 42:4.0.1.1.4.1 | SUBPART A
| Subpart A - Federal Matching and General Administration Provisions | |
| 42:4.0.1.1.4.1.17.1 | SECTION 433.8
| 433.8 [Reserved] | |
| 42:4.0.1.1.4.1.17.2 | SECTION 433.10
| 433.10 Rates of FFP for program services. | |
| 42:4.0.1.1.4.1.17.3 | SECTION 433.11
| 433.11 Enhanced FMAP rate for children. | |
| 42:4.0.1.1.4.1.17.4 | SECTION 433.15
| 433.15 Rates of FFP for administration. | |
| 42:4.0.1.1.4.1.17.5 | SECTION 433.32
| 433.32 Fiscal policies and accountability. | |
| 42:4.0.1.1.4.1.17.6 | SECTION 433.34
| 433.34 Cost allocation. | |
| 42:4.0.1.1.4.1.17.7 | SECTION 433.35
| 433.35 Equipment - Federal financial participation. | |
| 42:4.0.1.1.4.1.17.8 | SECTION 433.36
| 433.36 Liens and recoveries. | |
| 42:4.0.1.1.4.1.17.9 | SECTION 433.37
| 433.37 Reporting provider payments to Internal Revenue Service. | |
| 42:4.0.1.1.4.1.17.10 | SECTION 433.38
| 433.38 Interest charge on disallowed claims for FFP. | |
| 42:4.0.1.1.4.1.17.11 | SECTION 433.40
| 433.40 Treatment of uncashed or cancelled (voided) Medicaid checks. | |
| 42:4.0.1.1.4.2 | SUBPART B
| Subpart B - General Administrative Requirements State Financial Participation | |
| 42:4.0.1.1.4.2.17.1 | SECTION 433.50
| 433.50 Basis, scope, and applicability. | |
| 42:4.0.1.1.4.2.17.2 | SECTION 433.51
| 433.51 Public Funds as the State share of financial participation. | |
| 42:4.0.1.1.4.2.17.3 | SECTION 433.52
| 433.52 General definitions. | |
| 42:4.0.1.1.4.2.17.4 | SECTION 433.53
| 433.53 State plan requirements. | |
| 42:4.0.1.1.4.2.17.5 | SECTION 433.54
| 433.54 Bona fide donations. | |
| 42:4.0.1.1.4.2.17.6 | SECTION 433.55
| 433.55 Health care-related taxes defined. | |
| 42:4.0.1.1.4.2.17.7 | SECTION 433.56
| 433.56 Classes of health care services and providers defined. | |
| 42:4.0.1.1.4.2.17.8 | SECTION 433.57
| 433.57 General rules regarding revenues from provider-related donations and health care-related taxes. | |
| 42:4.0.1.1.4.2.17.9 | SECTION 433.58-433.60
| 433.58-433.60 [Reserved] | |
| 42:4.0.1.1.4.2.17.10 | SECTION 433.66
| 433.66 Permissible provider-related donations. | |
| 42:4.0.1.1.4.2.17.11 | SECTION 433.67
| 433.67 Limitations on level of FFP for permissible provider-related donations. | |
| 42:4.0.1.1.4.2.17.12 | SECTION 433.68
| 433.68 Permissible health care-related taxes. | |
| 42:4.0.1.1.4.2.17.13 | SECTION 433.70
| 433.70 Limitation on level of FFP for revenues from health care-related taxes. | |
| 42:4.0.1.1.4.2.17.14 | SECTION 433.72
| 433.72 Waiver provisions applicable to health care-related taxes. | |
| 42:4.0.1.1.4.2.17.15 | SECTION 433.74
| 433.74 Reporting requirements. | |
| 42:4.0.1.1.4.3 | SUBPART C
| Subpart C - Mechanized Claims Processing and Information Retrieval Systems | |
| 42:4.0.1.1.4.3.17.1 | SECTION 433.110
| 433.110 Basis, purpose, and applicability. | |
| 42:4.0.1.1.4.3.17.2 | SECTION 433.111
| 433.111 Definitions. | |
| 42:4.0.1.1.4.3.17.3 | SECTION 433.112
| 433.112 FFP for design, development, installation or enhancement of mechanized processing and information retrieval systems. | |
| 42:4.0.1.1.4.3.17.4 | SECTION 433.114
| 433.114 Procedures for obtaining initial approval; notice of decision. | |
| 42:4.0.1.1.4.3.17.5 | SECTION 433.116
| 433.116 FFP for operation of mechanized claims processing and information retrieval systems. | |
| 42:4.0.1.1.4.3.17.6 | SECTION 433.117
| 433.117 Initial approval of replacement systems. | |
| 42:4.0.1.1.4.3.17.7 | SECTION 433.119
| 433.119 Conditions for reapproval; notice of decision. | |
| 42:4.0.1.1.4.3.17.8 | SECTION 433.120
| 433.120 Procedures for reduction of FFP after reapproval review. | |
| 42:4.0.1.1.4.3.17.9 | SECTION 433.121
| 433.121 Reconsideration of the decision to reduce FFP after reapproval review. | |
| 42:4.0.1.1.4.3.17.10 | SECTION 433.122
| 433.122 Reapproval of a disapproved system. | |
| 42:4.0.1.1.4.3.17.11 | SECTION 433.123
| 433.123 Notification of changes in system requirements, performance standards or other conditions for approval or reapproval. | |
| 42:4.0.1.1.4.3.17.12 | SECTION 433.127
| 433.127 Termination of FFP for failure to provide access to claims processing and information retrieval systems. | |
| 42:4.0.1.1.4.3.17.13 | SECTION 433.131
| 433.131 Waiver for noncompliance with conditions of approval and reapproval. | |
| 42:4.0.1.1.4.4 | SUBPART D
| Subpart D - Third Party Liability | |
| 42:4.0.1.1.4.4.17 | SUBJGRP 17
| Assignment of Rights to Benefits | |
| 42:4.0.1.1.4.4.17.1 | SECTION 433.135
| 433.135 Basis and purpose. | |
| 42:4.0.1.1.4.4.17.2 | SECTION 433.136
| 433.136 Definitions. | |
| 42:4.0.1.1.4.4.17.3 | SECTION 433.137
| 433.137 State plan requirements. | |
| 42:4.0.1.1.4.4.17.4 | SECTION 433.138
| 433.138 Identifying liable third parties. | |
| 42:4.0.1.1.4.4.17.5 | SECTION 433.139
| 433.139 Payment of claims. | |
| 42:4.0.1.1.4.4.17.6 | SECTION 433.140
| 433.140 FFP and repayment of Federal share. | |
| 42:4.0.1.1.4.4.17.7 | SECTION 433.145
| 433.145 Assignment of rights to benefits - State plan requirements. | |
| 42:4.0.1.1.4.4.17.8 | SECTION 433.146
| 433.146 Rights assigned; assignment method. | |
| 42:4.0.1.1.4.4.17.9 | SECTION 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. | |
| 42:4.0.1.1.4.4.17.10 | SECTION 433.148
| 433.148 Denial or termination of eligibility. | |
| 42:4.0.1.1.4.4.18 | SUBJGRP 18
| Cooperative Agreements and Incentive Payments | |
| 42:4.0.1.1.4.4.18.11 | SECTION 433.151
| 433.151 Cooperative agreements and incentive payments - State plan requirements. | |
| 42:4.0.1.1.4.4.18.12 | SECTION 433.152
| 433.152 Requirements for cooperative agreements for third party collections. | |
| 42:4.0.1.1.4.4.18.13 | SECTION 433.153
| 433.153 Incentive payments to States and political subdivisions. | |
| 42:4.0.1.1.4.4.18.14 | SECTION 433.154
| 433.154 Distribution of collections. | |
| 42:4.0.1.1.4.5 | SUBPART E
| Subpart E - Methodologies for Determining Federal Share of Medicaid Expenditures for Adult Eligibility Group | |
| 42:4.0.1.1.4.5.19.1 | SECTION 433.202
| 433.202 Scope. | |
| 42:4.0.1.1.4.5.19.2 | SECTION 433.204
| 433.204 Definitions. | |
| 42:4.0.1.1.4.5.19.3 | SECTION 433.206
| 433.206 Threshold methodology. | |
| 42:4.0.1.1.4.6 | SUBPART F
| Subpart F - Refunding of Federal Share of Medicaid Overpayments to Providers | |
| 42:4.0.1.1.4.6.19.1 | SECTION 433.300
| 433.300 Basis. | |
| 42:4.0.1.1.4.6.19.2 | SECTION 433.302
| 433.302 Scope of subpart. | |
| 42:4.0.1.1.4.6.19.3 | SECTION 433.304
| 433.304 Definitions. | |
| 42:4.0.1.1.4.6.19.4 | SECTION 433.310
| 433.310 Applicability of requirements. | |
| 42:4.0.1.1.4.6.19.5 | SECTION 433.312
| 433.312 Basic requirements for refunds. | |
| 42:4.0.1.1.4.6.19.6 | SECTION 433.316
| 433.316 When discovery of overpayment occurs and its significance. | |
| 42:4.0.1.1.4.6.19.7 | SECTION 433.318
| 433.318 Overpayments involving providers who are bankrupt or out of business. | |
| 42:4.0.1.1.4.6.19.8 | SECTION 433.320
| 433.320 Procedures for refunds to CMS. | |
| 42:4.0.1.1.4.6.19.9 | SECTION 433.322
| 433.322 Maintenance of Records. | |
| 42:4.0.1.1.4.7 | SUBPART G
| Subpart G - Temporary FMAP Increase During the Public Health Emergency for COVID-19 | |
| 42:4.0.1.1.4.7.19.1 | SECTION 433.400
| 433.400 Continued enrollment for temporary FMAP increase. | |
| 42:4.0.1.1.5 | PART 434
| PART 434 - CONTRACTS | |
| 42:4.0.1.1.5.1 | SUBPART A
| Subpart A - General Provisions | |
| 42:4.0.1.1.5.1.19.1 | SECTION 434.1
| 434.1 Basis and scope. | |
| 42:4.0.1.1.5.1.19.2 | SECTION 434.2
| 434.2 Definitions. | |
| 42:4.0.1.1.5.1.19.3 | SECTION 434.4
| 434.4 State plan requirement. | |
| 42:4.0.1.1.5.1.19.4 | SECTION 434.6
| 434.6 General requirements for all contracts and subcontracts. | |
| 42:4.0.1.1.5.2 | SUBPART B
| Subpart B - Contracts with Fiscal Agents and Private Nonmedical Institutions | |
| 42:4.0.1.1.5.2.19.1 | SECTION 434.10
| 434.10 Contracts with fiscal agents. | |
| 42:4.0.1.1.5.2.19.2 | SECTION 434.12
| 434.12 Contracts with private nonmedical institutions. | |
| 42:4.0.1.1.5.2.19.3 | SECTION 434.14
| 434.14 [Reserved] | |
| 42:4.0.1.1.5.3 | SUBPART C
| Subpart C [Reserved] | |
| 42:4.0.1.1.5.4 | SUBPART D
| Subpart D - Contracts With Health Insuring Organizations | |
| 42:4.0.1.1.5.4.19.1 | SECTION 434.40
| 434.40 Contract requirements. | |
| 42:4.0.1.1.5.5 | SUBPART E
| Subpart E [Reserved] | |
| 42:4.0.1.1.5.6 | SUBPART F
| Subpart F - Federal Financial Participation | |
| 42:4.0.1.1.5.6.19.1 | SECTION 434.70
| 434.70 Conditions for Federal Financial Participation (FFP). | |
| 42:4.0.1.1.5.6.19.2 | SECTION 434.76
| 434.76 Costs under fiscal agent contracts. | |
| 42:4.0.1.1.5.6.19.3 | SECTION 434.78
| 434.78 Right to reconsideration of disallowance. | |
| 42:4.0.1.1.6 | PART 435
| PART 435 - ELIGIBILITY IN THE STATES, DISTRICT OF COLUMBIA, THE NORTHERN MARIANA ISLANDS, AND AMERICAN SAMOA | |
| 42:4.0.1.1.6.1 | SUBPART A
| Subpart A - General Provisions and Definitions | |
| 42:4.0.1.1.6.1.48.1 | SECTION 435.2
| 435.2 Purpose and applicability. | |
| 42:4.0.1.1.6.1.48.2 | SECTION 435.3
| 435.3 Basis. | |
| 42:4.0.1.1.6.1.48.3 | SECTION 435.4
| 435.4 Definitions and use of terms. | |
| 42:4.0.1.1.6.1.48.4 | SECTION 435.10
| 435.10 State plan requirements. | |
| 42:4.0.1.1.6.2 | SUBPART B
| Subpart B - Mandatory Coverage | |
| 42:4.0.1.1.6.2.48 | SUBJGRP 48
| Mandatory Coverage of Families and Children | |
| 42:4.0.1.1.6.2.48.1 | SECTION 435.100
| 435.100 Scope. | |
| 42:4.0.1.1.6.2.48.2 | SECTION 435.110
| 435.110 Parents and other caretaker relatives. | |
| 42:4.0.1.1.6.2.48.3 | SECTION 435.112
| 435.112 Families terminated from AFDC because of increased earnings or hours of employment. | |
| 42:4.0.1.1.6.2.48.4 | SECTION 435.115
| 435.115 Families with Medicaid eligibility extended because of increased collection of spousal support. | |
| 42:4.0.1.1.6.2.49 | SUBJGRP 49
| Mandatory Coverage of Pregnant Women, Children Under 19, and Newborn Children | |
| 42:4.0.1.1.6.2.49.5 | SECTION 435.116
| 435.116 Pregnant women. | |
| 42:4.0.1.1.6.2.49.6 | SECTION 435.117
| 435.117 Deemed newborn children. | |
| 42:4.0.1.1.6.2.50 | SUBJGRP 50
| Mandatory Coverage of Qualified Family Members | |
| 42:4.0.1.1.6.2.50.7 | SECTION 435.118
| 435.118 Infants and children under age 19. | |
| 42:4.0.1.1.6.2.51 | SUBJGRP 51
| Mandatory Coverage for Individuals Age 19 Through 64 | |
| 42:4.0.1.1.6.2.51.8 | SECTION 435.119
| 435.119 Coverage for individuals age 19 or older and under age 65 at or below 133 percent FPL. | |
| 42:4.0.1.1.6.2.52 | SUBJGRP 52
| Mandatory Coverage of the Aged, Blind, and Disabled | |
| 42:4.0.1.1.6.2.52.9 | SECTION 435.120
| 435.120 Individuals receiving SSI. | |
| 42:4.0.1.1.6.2.52.10 | SECTION 435.121
| 435.121 Individuals in States using more restrictive requirements for Medicaid than the SSI requirements. | |
| 42:4.0.1.1.6.2.52.11 | SECTION 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. | |
| 42:4.0.1.1.6.2.52.12 | SECTION 435.130
| 435.130 Individuals receiving mandatory State supplements. | |
| 42:4.0.1.1.6.2.52.13 | SECTION 435.131
| 435.131 Individuals eligible as essential spouses in December 1973. | |
| 42:4.0.1.1.6.2.52.14 | SECTION 435.132
| 435.132 Institutionalized individuals who were eligible in December 1973. | |
| 42:4.0.1.1.6.2.52.15 | SECTION 435.133
| 435.133 Blind and disabled individuals eligible in December 1973. | |
| 42:4.0.1.1.6.2.52.16 | SECTION 435.134
| 435.134 Individuals who would be eligible except for the increase in OASDI benefits under Pub. L. 92-336 (July 1, 1972). | |
| 42:4.0.1.1.6.2.52.17 | SECTION 435.135
| 435.135 Individuals who become ineligible for cash assistance as a result of OASDI cost-of-living increases received after April 1977. | |
| 42:4.0.1.1.6.2.52.18 | SECTION 435.136
| 435.136 State agency implementation requirements for one-time notice and annual review system. | |
| 42:4.0.1.1.6.2.52.19 | SECTION 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. | |
| 42:4.0.1.1.6.2.52.20 | SECTION 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. | |
| 42:4.0.1.1.6.2.53 | SUBJGRP 53
| Mandatory Coverage of Certain Aliens | |
| 42:4.0.1.1.6.2.53.21 | SECTION 435.139
| 435.139 Coverage for certain aliens. | |
| 42:4.0.1.1.6.2.54 | SUBJGRP 54
| Mandatory Coverage of Adoption Assistance and Foster Care Children | |
| 42:4.0.1.1.6.2.54.22 | SECTION 435.145
| 435.145 Children with adoption assistance, foster care, or guardianship care under title IV-E. | |
| 42:4.0.1.1.6.2.54.23 | SECTION 435.150
| 435.150 Former foster care children. | |
| 42:4.0.1.1.6.2.55 | SUBJGRP 55
| Mandatory Coverage of Special Groups | |
| 42:4.0.1.1.6.2.55.24 | SECTION 435.170
| 435.170 Pregnant women eligible for extended or continuous eligibility. | |
| 42:4.0.1.1.6.2.55.25 | SECTION 435.172
| 435.172 Continuous eligibility for hospitalized children. | |
| 42:4.0.1.1.6.3 | SUBPART C
| Subpart C - Options for Coverage | |
| 42:4.0.1.1.6.3.56 | SUBJGRP 56
| Options for Coverage of Families and Children and the Aged, Blind, and Disabled | |
| 42:4.0.1.1.6.3.56.1 | SECTION 435.200
| 435.200 Scope. | |
| 42:4.0.1.1.6.3.56.2 | SECTION 435.201
| 435.201 Individuals included in optional groups. | |
| 42:4.0.1.1.6.3.56.3 | SECTION 435.210
| 435.210 Optional eligibility for individuals who meet the income and resource requirements of the cash assistance programs. | |
| 42:4.0.1.1.6.3.56.4 | SECTION 435.211
| 435.211 Optional eligibility for individuals who would be eligible for cash assistance if they were not in medical institutions. | |
| 42:4.0.1.1.6.3.56.5 | SECTION 435.212
| 435.212 Individuals who would be ineligible if they were not enrolled in an MCO or PCCM. | |
| 42:4.0.1.1.6.3.56.6 | SECTION 435.213
| 435.213 Optional eligibility for individuals needing treatment for breast or cervical cancer. | |
| 42:4.0.1.1.6.3.56.7 | SECTION 435.214
| 435.214 Eligibility for Medicaid limited to family planning and related services. | |
| 42:4.0.1.1.6.3.56.8 | SECTION 435.215
| 435.215 Individuals infected with tuberculosis. | |
| 42:4.0.1.1.6.3.56.9 | SECTION 435.217
| 435.217 Individuals receiving home and community-based services. | |
| 42:4.0.1.1.6.3.56.10 | SECTION 435.218
| 435.218 Individuals with MAGI-based income above 133 percent FPL. | |
| 42:4.0.1.1.6.3.56.11 | SECTION 435.219
| 435.219 Individuals receiving State plan home and community-based services. | |
| 42:4.0.1.1.6.3.57 | SUBJGRP 57
| Options for Coverage of Families and Children | |
| 42:4.0.1.1.6.3.57.12 | SECTION 435.220
| 435.220 Optional eligibility for parents and other caretaker relatives. | |
| 42:4.0.1.1.6.3.57.13 | SECTION 435.221
| 435.221 [Reserved] | |
| 42:4.0.1.1.6.3.57.14 | SECTION 435.222
| 435.222 Optional eligibility for reasonable classifications of individuals under age 21. | |
| 42:4.0.1.1.6.3.57.15 | SECTION 435.225
| 435.225 Individuals under age 19 who would be eligible for Medicaid if they were in a medical institution. | |
| 42:4.0.1.1.6.3.57.16 | SECTION 435.226
| 435.226 Optional eligibility for independent foster care adolescents. | |
| 42:4.0.1.1.6.3.57.17 | SECTION 435.227
| 435.227 Optional eligibility for individuals under age 21 who are under State adoption assistance agreements. | |
| 42:4.0.1.1.6.3.57.18 | SECTION 435.229
| 435.229 Optional targeted low-income children. | |
| 42:4.0.1.1.6.3.58 | SUBJGRP 58
| Options for Coverage of the Aged, Blind, and Disabled | |
| 42:4.0.1.1.6.3.58.19 | SECTION 435.230
| 435.230 Aged, blind, and disabled individuals in States that use more restrictive requirements for Medicaid than SSI requirements: Optional coverage. | |
| 42:4.0.1.1.6.3.58.20 | SECTION 435.232
| 435.232 Individuals receiving only optional State supplements. | |
| 42:4.0.1.1.6.3.58.21 | SECTION 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. | |
| 42:4.0.1.1.6.3.58.22 | SECTION 435.236
| 435.236 Individuals in institutions who are eligible under a special income level. | |
| 42:4.0.1.1.6.4 | SUBPART D
| Subpart D - Optional Coverage of the Medically Needy | |
| 42:4.0.1.1.6.4.59.1 | SECTION 435.300
| 435.300 Scope. | |
| 42:4.0.1.1.6.4.59.2 | SECTION 435.301
| 435.301 General rules. | |
| 42:4.0.1.1.6.4.59.3 | SECTION 435.308
| 435.308 Medically needy coverage of individuals under age 21. | |
| 42:4.0.1.1.6.4.59.4 | SECTION 435.310
| 435.310 Medically needy coverage of parents and other caretaker relatives. | |
| 42:4.0.1.1.6.4.59.5 | SECTION 435.320
| 435.320 Medically needy coverage of the aged in States that cover individuals receiving SSI. | |
| 42:4.0.1.1.6.4.59.6 | SECTION 435.322
| 435.322 Medically needy coverage of the blind in States that cover individuals receiving SSI. | |
| 42:4.0.1.1.6.4.59.7 | SECTION 435.324
| 435.324 Medically needy coverage of the disabled in States that cover individuals receiving SSI. | |
| 42:4.0.1.1.6.4.59.8 | SECTION 435.326
| 435.326 Individuals who would be ineligible if they were not enrolled in an MCO or PCCM. | |
| 42:4.0.1.1.6.4.59.9 | SECTION 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. | |
| 42:4.0.1.1.6.4.59.10 | SECTION 435.340
| 435.340 Protected medically needy coverage for blind and disabled individuals eligible in December 1973. | |
| 42:4.0.1.1.6.4.59.11 | SECTION 435.350
| 435.350 Coverage for certain aliens. | |
| 42:4.0.1.1.6.5 | SUBPART E
| Subpart E - General Eligibility Requirements | |
| 42:4.0.1.1.6.5.59.1 | SECTION 435.400
| 435.400 Scope. | |
| 42:4.0.1.1.6.5.59.2 | SECTION 435.401
| 435.401 General rules. | |
| 42:4.0.1.1.6.5.59.3 | SECTION 435.402
| 435.402 [Reserved] | |
| 42:4.0.1.1.6.5.59.4 | SECTION 435.403
| 435.403 State residence. | |
| 42:4.0.1.1.6.5.59.5 | SECTION 435.404
| 435.404 Applicant's choice of category. | |
| 42:4.0.1.1.6.5.59.6 | SECTION 435.406
| 435.406 Citizenship and non-citizen eligibility. | |
| 42:4.0.1.1.6.5.59.7 | SECTION 435.407
| 435.407 Types of acceptable documentary evidence of citizenship. | |
| 42:4.0.1.1.6.6 | SUBPART F
| Subpart F - Categorical Requirements for Eligibility | |
| 42:4.0.1.1.6.6.59 | SUBJGRP 59
| Age | |
| 42:4.0.1.1.6.6.59.1 | SECTION 435.500
| 435.500 Scope. | |
| 42:4.0.1.1.6.6.59.2 | SECTION 435.520
| 435.520 Age requirements for the aged. | |
| 42:4.0.1.1.6.6.60 | SUBJGRP 60
| Blindness | |
| 42:4.0.1.1.6.6.60.3 | SECTION 435.530
| 435.530 Definition of blindness. | |
| 42:4.0.1.1.6.6.60.4 | SECTION 435.531
| 435.531 Determinations of blindness. | |
| 42:4.0.1.1.6.6.61 | SUBJGRP 61
| Disability | |
| 42:4.0.1.1.6.6.61.5 | SECTION 435.540
| 435.540 Definition of disability. | |
| 42:4.0.1.1.6.6.61.6 | SECTION 435.541
| 435.541 Determinations of disability. | |
| 42:4.0.1.1.6.7 | SUBPART G
| Subpart G - General Financial Eligibility Requirements and Options | |
| 42:4.0.1.1.6.7.62.1 | SECTION 435.600
| 435.600 Scope. | |
| 42:4.0.1.1.6.7.62.2 | SECTION 435.601
| 435.601 Application of financial eligibility methodologies. | |
| 42:4.0.1.1.6.7.62.3 | SECTION 435.602
| 435.602 Financial responsibility of relatives and other individuals. | |
| 42:4.0.1.1.6.7.62.4 | SECTION 435.603
| 435.603 Application of modified adjusted gross income (MAGI). | |
| 42:4.0.1.1.6.7.62.5 | SECTION 435.604
| 435.604 [Reserved] | |
| 42:4.0.1.1.6.7.62.6 | SECTION 435.606
| 435.606 [Reserved] | |
| 42:4.0.1.1.6.7.62.7 | SECTION 435.608
| 435.608 Applications for other benefits. | |
| 42:4.0.1.1.6.7.62.8 | SECTION 435.610
| 435.610 Assignment of rights to benefits. | |
| 42:4.0.1.1.6.7.62.9 | SECTION 435.622
| 435.622 Individuals in institutions who are eligible under a special income level. | |
| 42:4.0.1.1.6.7.62.10 | SECTION 435.631
| 435.631 General requirements for determining income eligibility in States using more restrictive requirements for Medicaid than SSI. | |
| 42:4.0.1.1.6.7.62.11 | SECTION 435.640
| 435.640 Protected Medicaid eligibility for individuals eligible in December 1973. | |
| 42:4.0.1.1.6.8 | SUBPART H
| Subpart H - Specific Post-Eligibility Financial Requirements for the Categorically Needy | |
| 42:4.0.1.1.6.8.62.1 | SECTION 435.700
| 435.700 Scope. | |
| 42:4.0.1.1.6.8.62.2 | SECTION 435.725
| 435.725 Post-eligibility treatment of income of institutionalized individuals in SSI States: Application of patient income to the cost of care. | |
| 42:4.0.1.1.6.8.62.3 | SECTION 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. | |
| 42:4.0.1.1.6.8.62.4 | SECTION 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. | |
| 42:4.0.1.1.6.8.62.5 | SECTION 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. | |
| 42:4.0.1.1.6.9 | SUBPART I
| Subpart I - Specific Eligibility and Post-Eligibility Financial Requirements for the Medically Needy | |
| 42:4.0.1.1.6.9.62 | SUBJGRP 62
| Medically Needy Income Standard | |
| 42:4.0.1.1.6.9.62.1 | SECTION 435.800
| 435.800 Scope. | |
| 42:4.0.1.1.6.9.62.2 | SECTION 435.811
| 435.811 Medically needy income standard: General requirements. | |
| 42:4.0.1.1.6.9.62.3 | SECTION 435.814
| 435.814 Medically needy income standard: State plan requirements. | |
| 42:4.0.1.1.6.9.63 | SUBJGRP 63
| Medically Needy Income Eligibility | |
| 42:4.0.1.1.6.9.63.4 | SECTION 435.831
| 435.831 Income eligibility. | |
| 42:4.0.1.1.6.9.63.5 | SECTION 435.832
| 435.832 Post-eligibility treatment of income of institutionalized individuals: Application of patient income to the cost of care. | |
| 42:4.0.1.1.6.9.64 | SUBJGRP 64
| Medically Needy Resource Standard | |
| 42:4.0.1.1.6.9.64.6 | SECTION 435.840
| 435.840 Medically needy resource standard: General requirements. | |
| 42:4.0.1.1.6.9.64.7 | SECTION 435.843
| 435.843 Medically needy resource standard: State plan requirements. | |
| 42:4.0.1.1.6.9.65 | SUBJGRP 65
| Determining Eligibility on the Basis of Resources | |
| 42:4.0.1.1.6.9.65.8 | SECTION 435.845
| 435.845 Medically needy resource eligibility. | |
| 42:4.0.1.1.6.9.65.9 | SECTION 435.850-435.852
| 435.850-435.852 [Reserved] | |
| 42:4.0.1.1.6.10 | SUBPART J
| Subpart J - Eligibility in the States and District of Columbia | |
| 42:4.0.1.1.6.10.66 | SUBJGRP 66
| General Methods of Administration | |
| 42:4.0.1.1.6.10.66.1 | SECTION 435.900
| 435.900 Scope. | |
| 42:4.0.1.1.6.10.66.2 | SECTION 435.901
| 435.901 Consistency with objectives and statutes. | |
| 42:4.0.1.1.6.10.66.3 | SECTION 435.902
| 435.902 Simplicity of administration. | |
| 42:4.0.1.1.6.10.66.4 | SECTION 435.903
| 435.903 Adherence of local agencies to State plan requirements. | |
| 42:4.0.1.1.6.10.66.5 | SECTION 435.904
| 435.904 Establishment of outstation locations to process applications for certain low-income eligibility groups. | |
| 42:4.0.1.1.6.10.67 | SUBJGRP 67
| Applications | |
| 42:4.0.1.1.6.10.67.6 | SECTION 435.905
| 435.905 Availability and accessibility of program information. | |
| 42:4.0.1.1.6.10.67.7 | SECTION 435.906
| 435.906 Opportunity to apply. | |
| 42:4.0.1.1.6.10.67.8 | SECTION 435.907
| 435.907 Application. | |
| 42:4.0.1.1.6.10.67.9 | SECTION 435.908
| 435.908 Assistance with application and renewal. | |
| 42:4.0.1.1.6.10.67.10 | SECTION 435.909
| 435.909 Automatic entitlement to Medicaid following a determination of eligibility under other programs. | |
| 42:4.0.1.1.6.10.67.11 | SECTION 435.910
| 435.910 Use of social security number. | |
| 42:4.0.1.1.6.10.68 | SUBJGRP 68
| Determination of Medicaid Eligibility | |
| 42:4.0.1.1.6.10.68.12 | SECTION 435.911
| 435.911 Determination of eligibility. | |
| 42:4.0.1.1.6.10.68.13 | SECTION 435.912
| 435.912 Timely determination of eligibility. | |
| 42:4.0.1.1.6.10.68.14 | SECTION 435.914
| 435.914 Case documentation. | |
| 42:4.0.1.1.6.10.68.15 | SECTION 435.915
| 435.915 Effective date. | |
| 42:4.0.1.1.6.10.69 | SUBJGRP 69
| Redeterminations of Medicaid Eligibility | |
| 42:4.0.1.1.6.10.69.16 | SECTION 435.916
| 435.916 Periodic renewal of Medicaid eligibility. | |
| 42:4.0.1.1.6.10.69.17 | SECTION 435.917
| 435.917 Notice of agency's decision concerning eligibility, benefits, or services. | |
| 42:4.0.1.1.6.10.69.18 | SECTION 435.918
| 435.918 Use of electronic notices. | |
| 42:4.0.1.1.6.10.69.19 | SECTION 435.920
| 435.920 Verification of SSNs. | |
| 42:4.0.1.1.6.10.69.20 | SECTION 435.923
| 435.923 Authorized representatives. | |
| 42:4.0.1.1.6.10.69.21 | SECTION 435.926
| 435.926 Continuous eligibility for children. | |
| 42:4.0.1.1.6.10.70 | SUBJGRP 70
| Furnishing Medicaid | |
| 42:4.0.1.1.6.10.70.22 | SECTION 435.930
| 435.930 Furnishing Medicaid. | |
| 42:4.0.1.1.6.10.71 | SUBJGRP 71
| Income and Eligibility Verification Requirements | |
| 42:4.0.1.1.6.10.71.23 | SECTION 435.940
| 435.940 Basis and scope. | |
| 42:4.0.1.1.6.10.71.24 | SECTION 435.945
| 435.945 General requirements. | |
| 42:4.0.1.1.6.10.71.25 | SECTION 435.948
| 435.948 Verifying financial information. | |
| 42:4.0.1.1.6.10.71.26 | SECTION 435.949
| 435.949 Verification of information through an electronic service. | |
| 42:4.0.1.1.6.10.71.27 | SECTION 435.952
| 435.952 Use of information and requests of additional information from individuals. | |
| 42:4.0.1.1.6.10.71.28 | SECTION 435.956
| 435.956 Verification of other non-financial information. | |
| 42:4.0.1.1.6.10.71.29 | SECTION 435.960
| 435.960 Standardized formats for furnishing and obtaining information to verifying income and eligibility. | |
| 42:4.0.1.1.6.10.71.30 | SECTION 435.965
| 435.965 Delay of effective date. | |
| 42:4.0.1.1.6.11 | SUBPART K
| Subpart K - Federal Financial Participation | |
| 42:4.0.1.1.6.11.72 | SUBJGRP 72
| FFP in Expenditures for Determining Eligibility and Providing Services | |
| 42:4.0.1.1.6.11.72.1 | SECTION 435.1000
| 435.1000 Scope. | |
| 42:4.0.1.1.6.11.72.2 | SECTION 435.1001
| 435.1001 FFP for administration. | |
| 42:4.0.1.1.6.11.72.3 | SECTION 435.1002
| 435.1002 FFP for services. | |
| 42:4.0.1.1.6.11.72.4 | SECTION 435.1003
| 435.1003 FFP for redeterminations. | |
| 42:4.0.1.1.6.11.72.5 | SECTION 435.1004
| 435.1004 Beneficiaries overcoming certain conditions of eligibility. | |
| 42:4.0.1.1.6.11.73 | SUBJGRP 73
| Limitations on FFP | |
| 42:4.0.1.1.6.11.73.6 | SECTION 435.1005
| 435.1005 Beneficiaries in institutions eligible under a special income standard. | |
| 42:4.0.1.1.6.11.73.7 | SECTION 435.1006
| 435.1006 Beneficiaries of optional State supplements only. | |
| 42:4.0.1.1.6.11.73.8 | SECTION 435.1007
| 435.1007 Categorically needy, medically needy, and qualified Medicare beneficiaries. | |
| 42:4.0.1.1.6.11.73.9 | SECTION 435.1008
| 435.1008 FFP in expenditures for medical assistance for individuals who have declared citizenship or nationality or satisfactory immigration status. | |
| 42:4.0.1.1.6.11.73.10 | SECTION 435.1009
| 435.1009 Institutionalized individuals. | |
| 42:4.0.1.1.6.11.73.11 | SECTION 435.1010
| 435.1010 Definitions relating to institutional status. | |
| 42:4.0.1.1.6.11.74 | SUBJGRP 74
| Requirements for State Supplements | |
| 42:4.0.1.1.6.11.74.12 | SECTION 435.1011
| 435.1011 Requirement for mandatory State supplements. | |
| 42:4.0.1.1.6.11.74.13 | SECTION 435.1012
| 435.1012 Requirement for maintenance of optional State supplement expenditures. | |
| 42:4.0.1.1.6.11.75 | SUBJGRP 75
| FFP for Premium Assistance | |
| 42:4.0.1.1.6.11.75.14 | SECTION 435.1015
| 435.1015 FFP for premium assistance for plans in the individual market. | |
| 42:4.0.1.1.6.12 | SUBPART L
| Subpart L - Options for Coverage of Special Groups under Presumptive Eligibility | |
| 42:4.0.1.1.6.12.76.1 | SECTION 435.1100
| 435.1100 Basis for presumptive eligibility. | |
| 42:4.0.1.1.6.12.76.2 | SECTION 435.1101
| 435.1101 Definitions related to presumptive eligibility. | |
| 42:4.0.1.1.6.12.76.3 | SECTION 435.1102
| 435.1102 Children covered under presumptive eligibility. | |
| 42:4.0.1.1.6.12.76.4 | SECTION 435.1103
| 435.1103 Presumptive eligibility for other individuals. | |
| 42:4.0.1.1.6.12.76.5 | SECTION 435.1110
| 435.1110 Presumptive eligibility determined by hospitals. | |
| 42:4.0.1.1.6.13 | SUBPART M
| Subpart M - Coordination of Eligibility and Enrollment Between Medicaid, CHIP, Exchanges and Other Insurance Affordability Programs | |
| 42:4.0.1.1.6.13.76.1 | SECTION 435.1200
| 435.1200 Medicaid agency responsibilities for a coordinated eligibility and enrollment process with other insurance affordability programs. | |
| 42:4.0.1.1.6.13.76.2 | SECTION 435.1205
| 435.1205 Alignment with exchange initial open enrollment period. | |
| 42:4.0.1.1.7 | PART 436
| PART 436 - ELIGIBILITY IN GUAM, PUERTO RICO, AND THE VIRGIN ISLANDS | |
| 42:4.0.1.1.7.1 | SUBPART A
| Subpart A - General Provisions and Definitions | |
| 42:4.0.1.1.7.1.88.1 | SECTION 436.1
| 436.1 Purpose and applicability. | |
| 42:4.0.1.1.7.1.88.2 | SECTION 436.2
| 436.2 Basis. | |
| 42:4.0.1.1.7.1.88.3 | SECTION 436.3
| 436.3 Definitions and use of terms. | |
| 42:4.0.1.1.7.1.88.4 | SECTION 436.10
| 436.10 State plan requirements. | |
| 42:4.0.1.1.7.2 | SUBPART B
| Subpart B - Mandatory Coverage of the Categorically Needy | |
| 42:4.0.1.1.7.2.88.1 | SECTION 436.100
| 436.100 Scope. | |
| 42:4.0.1.1.7.2.88.2 | SECTION 436.110
| 436.110 Individuals receiving cash assistance. | |
| 42:4.0.1.1.7.2.88.3 | SECTION 436.111
| 436.111 Individuals who are not eligible for cash assistance because of a requirement not applicable under Medicaid. | |
| 42:4.0.1.1.7.2.88.4 | SECTION 436.112
| 436.112 Individuals who would be eligible for cash assistance except for increased OASDI under Pub. L. 92-336 (July 1, 1972). | |
| 42:4.0.1.1.7.2.88.5 | SECTION 436.114
| 436.114 Individuals deemed to be receiving AFDC. | |
| 42:4.0.1.1.7.2.88.6 | SECTION 436.116
| 436.116 Families terminated from AFDC because of increased earnings or hours of employment. | |
| 42:4.0.1.1.7.2.88.7 | SECTION 436.118
| 436.118 Children for whom adoption assistance or foster care maintenance payments are made. | |
| 42:4.0.1.1.7.2.88.8 | SECTION 436.120
| 436.120 Qualified pregnant women and children who are not qualified family members. | |
| 42:4.0.1.1.7.2.88.9 | SECTION 436.121
| 436.121 Qualified family members. | |
| 42:4.0.1.1.7.2.88.10 | SECTION 436.122
| 436.122 Pregnant women eligible for extended coverage. | |
| 42:4.0.1.1.7.2.88.11 | SECTION 436.124
| 436.124 Newborn children. | |
| 42:4.0.1.1.7.2.88.12 | SECTION 436.128
| 436.128 Coverage for certain qualified aliens. | |
| 42:4.0.1.1.7.3 | SUBPART C
| Subpart C - Options for Coverage as Categorically Needy | |
| 42:4.0.1.1.7.3.88 | SUBJGRP 88
| Options for Coverage of Families and Children and Aged, Blind, and Disabled Individuals, Including Pregnant Women | |
| 42:4.0.1.1.7.3.88.1 | SECTION 436.200
| 436.200 Scope. | |
| 42:4.0.1.1.7.3.88.2 | SECTION 436.201
| 436.201 Individuals included in optional groups. | |
| 42:4.0.1.1.7.3.88.3 | SECTION 436.210
| 436.210 Individuals who meet the income and resource requirements of the cash assistance programs. | |
| 42:4.0.1.1.7.3.88.4 | SECTION 436.211
| 436.211 Individuals who would be eligible for cash assistance if they were not in medical institutions. | |
| 42:4.0.1.1.7.3.88.5 | SECTION 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. | |
| 42:4.0.1.1.7.3.88.6 | SECTION 436.217
| 436.217 Individuals receiving home and community-based services. | |
| 42:4.0.1.1.7.3.88.7 | SECTION 436.219
| 436.219 Individuals receiving State plan home and community-based services. | |
| 42:4.0.1.1.7.3.88.8 | SECTION 436.220
| 436.220 Individuals who would meet the income and resource requirements under AFDC if child care costs were paid from earnings. | |
| 42:4.0.1.1.7.3.88.9 | SECTION 436.222
| 436.222 Individuals under age 21 who meet the income and resource requirements of AFDC. | |
| 42:4.0.1.1.7.3.88.10 | SECTION 436.224
| 436.224 Individuals under age 21 who are under State adoption assistance agreements. | |
| 42:4.0.1.1.7.3.88.11 | SECTION 436.229
| 436.229 Optional targeted low-income children. | |
| 42:4.0.1.1.7.3.89 | SUBJGRP 89
| Options for Coverage of the Aged, Blind, and Disabled | |
| 42:4.0.1.1.7.3.89.12 | SECTION 436.230
| 436.230 Essential spouses of aged, blind, or disabled individuals receiving cash assistance. | |
| 42:4.0.1.1.7.4 | SUBPART D
| Subpart D - Optional Coverage of the Medically Needy | |
| 42:4.0.1.1.7.4.90.1 | SECTION 436.300
| 436.300 Scope. | |
| 42:4.0.1.1.7.4.90.2 | SECTION 436.301
| 436.301 General rules. | |
| 42:4.0.1.1.7.4.90.3 | SECTION 436.308
| 436.308 Medically needy coverage of individuals under age 21. | |
| 42:4.0.1.1.7.4.90.4 | SECTION 436.310
| 436.310 Medically needy coverage of specified relatives. | |
| 42:4.0.1.1.7.4.90.5 | SECTION 436.320
| 436.320 Medically needy coverage of the aged. | |
| 42:4.0.1.1.7.4.90.6 | SECTION 436.321
| 436.321 Medically needy coverage of the blind. | |
| 42:4.0.1.1.7.4.90.7 | SECTION 436.322
| 436.322 Medically needy coverage of the disabled. | |
| 42:4.0.1.1.7.4.90.8 | SECTION 436.330
| 436.330 Coverage for certain aliens. | |
| 42:4.0.1.1.7.5 | SUBPART E
| Subpart E - General Eligibility Requirements | |
| 42:4.0.1.1.7.5.90.1 | SECTION 436.400
| 436.400 Scope. | |
| 42:4.0.1.1.7.5.90.2 | SECTION 436.401
| 436.401 General rules. | |
| 42:4.0.1.1.7.5.90.3 | SECTION 436.402
| 436.402 [Reserved] | |
| 42:4.0.1.1.7.5.90.4 | SECTION 436.403
| 436.403 State residence. | |
| 42:4.0.1.1.7.5.90.5 | SECTION 436.404
| 436.404 Applicant's choice of category. | |
| 42:4.0.1.1.7.5.90.6 | SECTION 436.406
| 436.406 Citizenship and alienage. | |
| 42:4.0.1.1.7.5.90.7 | SECTION 436.407
| 436.407 Types of acceptable documentary evidence of citizenship. | |
| 42:4.0.1.1.7.5.90.8 | SECTION 436.408
| 436.408 [Reserved] | |
| 42:4.0.1.1.7.6 | SUBPART F
| Subpart F - Categorical Requirements for Medicaid Eligibility | |
| 42:4.0.1.1.7.6.90 | SUBJGRP 90
| Dependency | |
| 42:4.0.1.1.7.6.90.1 | SECTION 436.500
| 436.500 Scope. | |
| 42:4.0.1.1.7.6.90.2 | SECTION 436.510
| 436.510 Determination of dependency. | |
| 42:4.0.1.1.7.6.91 | SUBJGRP 91
| Age | |
| 42:4.0.1.1.7.6.91.3 | SECTION 436.520
| 436.520 Age requirements for the aged. | |
| 42:4.0.1.1.7.6.91.4 | SECTION 436.522
| 436.522 Determination of age. | |
| 42:4.0.1.1.7.6.92 | SUBJGRP 92
| Blindness | |
| 42:4.0.1.1.7.6.92.5 | SECTION 436.530
| 436.530 Definition of blindness. | |
| 42:4.0.1.1.7.6.92.6 | SECTION 436.531
| 436.531 Determination of blindness. | |
| 42:4.0.1.1.7.6.93 | SUBJGRP 93
| Disability | |
| 42:4.0.1.1.7.6.93.7 | SECTION 436.540
| 436.540 Definition of disability. | |
| 42:4.0.1.1.7.6.93.8 | SECTION 436.541
| 436.541 Determination of disability. | |
| 42:4.0.1.1.7.7 | SUBPART G
| Subpart G - General Financial Eligibility Requirements and Options | |
| 42:4.0.1.1.7.7.94.1 | SECTION 436.600
| 436.600 Scope. | |
| 42:4.0.1.1.7.7.94.2 | SECTION 436.601
| 436.601 Application of financial eligibility methodologies. | |
| 42:4.0.1.1.7.7.94.3 | SECTION 436.602
| 436.602 Financial responsibility of relatives and other individuals. | |
| 42:4.0.1.1.7.7.94.4 | SECTION 436.604
| 436.604 [Reserved] | |
| 42:4.0.1.1.7.7.94.5 | SECTION 436.606
| 436.606 [Reserved] | |
| 42:4.0.1.1.7.7.94.6 | SECTION 436.608
| 436.608 Applications for other benefits. | |
| 42:4.0.1.1.7.7.94.7 | SECTION 436.610
| 436.610 Assignment of rights to benefits. | |
| 42:4.0.1.1.7.8 | SUBPART H
| Subpart H [Reserved] | |
| 42:4.0.1.1.7.9 | SUBPART I
| Subpart I - Financial Requirements for the Medically Needy | |
| 42:4.0.1.1.7.9.94 | SUBJGRP 94
| Medically Needy Income Standard | |
| 42:4.0.1.1.7.9.94.1 | SECTION 436.800
| 436.800 Scope. | |
| 42:4.0.1.1.7.9.94.2 | SECTION 436.811
| 436.811 Medically needy income standard: General requirements. | |
| 42:4.0.1.1.7.9.94.3 | SECTION 436.814
| 436.814 Medically needy income standard: State plan requirements. | |
| 42:4.0.1.1.7.9.95 | SUBJGRP 95
| Medically Needy Income Eligibility and Liability for Payment of Medical Expenses | |
| 42:4.0.1.1.7.9.95.4 | SECTION 436.831
| 436.831 Income eligibility. | |
| 42:4.0.1.1.7.9.95.5 | SECTION 436.832
| 436.832 Post-eligibility treatment of income of institutionalized individuals: Application of patient income to the cost of care. | |
| 42:4.0.1.1.7.9.96 | SUBJGRP 96
| Medically Needy Resource Standard | |
| 42:4.0.1.1.7.9.96.6 | SECTION 436.840
| 436.840 Medically needy resource standard: General requirements. | |
| 42:4.0.1.1.7.9.96.7 | SECTION 436.843
| 436.843 Medically needy resource standard: State plan requirements. | |
| 42:4.0.1.1.7.9.97 | SUBJGRP 97
| Determining Eligibility on the Basis of Resources | |
| 42:4.0.1.1.7.9.97.8 | SECTION 436.845
| 436.845 Medically needy resource eligibility. | |
| 42:4.0.1.1.7.10 | SUBPART J
| Subpart J - Eligibility in Guam, Puerto Rico, and the Virgin Islands | |
| 42:4.0.1.1.7.10.98.1 | SECTION 436.900
| 436.900 Scope. | |
| 42:4.0.1.1.7.10.98.2 | SECTION 436.901
| 436.901 General requirements. | |
| 42:4.0.1.1.7.10.98.3 | SECTION 436.909
| 436.909 Automatic entitlement to Medicaid following a determination of eligibility under other programs. | |
| 42:4.0.1.1.7.11 | SUBPART K
| Subpart K - Federal Financial Participation (FFP) | |
| 42:4.0.1.1.7.11.98 | SUBJGRP 98
| FFP for Expenditures for Determining Eligibility and Providing Services | |
| 42:4.0.1.1.7.11.98.1 | SECTION 436.1000
| 436.1000 Scope. | |
| 42:4.0.1.1.7.11.98.2 | SECTION 436.1001
| 436.1001 FFP for administration. | |
| 42:4.0.1.1.7.11.98.3 | SECTION 436.1002
| 436.1002 FFP for services. | |
| 42:4.0.1.1.7.11.98.4 | SECTION 436.1003
| 436.1003 beneficiaries overcoming certain conditions of eligibility. | |
| 42:4.0.1.1.7.11.98.5 | SECTION 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. | |
| 42:4.0.1.1.7.11.98.6 | SECTION 436.1005
| 436.1005 Institutionalized individuals. | |
| 42:4.0.1.1.7.11.98.7 | SECTION 436.1006
| 436.1006 Definitions relating to institutional status. | |
| 42:4.0.1.1.7.12 | SUBPART L
| Subpart L - Option for Coverage of Special Groups | |
| 42:4.0.1.1.7.12.99 | SUBJGRP 99
| Presumptive Eligibility for Children | |
| 42:4.0.1.1.7.12.99.1 | SECTION 436.1100
| 436.1100 Basis and scope. | |
| 42:4.0.1.1.7.12.99.2 | SECTION 436.1101
| 436.1101 Definitions related to presumptive eligibility period for children. | |
| 42:4.0.1.1.7.12.99.3 | SECTION 436.1102
| 436.1102 General rules. | |
| 42:4.0.1.1.8 | PART 438
| PART 438 - MANAGED CARE | |
| 42:4.0.1.1.8.1 | SUBPART A
| Subpart A - General Provisions | |
| 42:4.0.1.1.8.1.100.1 | SECTION 438.1
| 438.1 Basis and scope. | |
| 42:4.0.1.1.8.1.100.2 | SECTION 438.2
| 438.2 Definitions. | |
| 42:4.0.1.1.8.1.100.3 | SECTION 438.3
| 438.3 Standard contract requirements. | |
| 42:4.0.1.1.8.1.100.4 | SECTION 438.4
| 438.4 Actuarial soundness. | |
| 42:4.0.1.1.8.1.100.5 | SECTION 438.5
| 438.5 Rate development standards. | |
| 42:4.0.1.1.8.1.100.6 | SECTION 438.6
| 438.6 Special contract provisions related to payment. | |
| 42:4.0.1.1.8.1.100.7 | SECTION 438.7
| 438.7 Rate certification submission. | |
| 42:4.0.1.1.8.1.100.8 | SECTION 438.8
| 438.8 Medical loss ratio (MLR) standards. | |
| 42:4.0.1.1.8.1.100.9 | SECTION 438.9
| 438.9 Provisions that apply to non-emergency medical transportation PAHPs. | |
| 42:4.0.1.1.8.1.100.10 | SECTION 438.10
| 438.10 Information requirements. | |
| 42:4.0.1.1.8.1.100.11 | SECTION 438.12
| 438.12 Provider discrimination prohibited. | |
| 42:4.0.1.1.8.1.100.12 | SECTION 438.14
| 438.14 Requirements that apply to MCO, PIHP, PAHP, PCCM, and PCCM entity contracts involving Indians, Indian health care providers (IHCPs), and Indian managed care entities (IMCEs). | |
| 42:4.0.1.1.8.2 | SUBPART B
| Subpart B - State Responsibilities | |
| 42:4.0.1.1.8.2.100.1 | SECTION 438.50
| 438.50 State Plan requirements. | |
| 42:4.0.1.1.8.2.100.2 | SECTION 438.52
| 438.52 Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities. | |
| 42:4.0.1.1.8.2.100.3 | SECTION 438.54
| 438.54 Managed care enrollment. | |
| 42:4.0.1.1.8.2.100.4 | SECTION 438.56
| 438.56 Disenrollment: Requirements and limitations. | |
| 42:4.0.1.1.8.2.100.5 | SECTION 438.58
| 438.58 Conflict of interest safeguards. | |
| 42:4.0.1.1.8.2.100.6 | SECTION 438.60
| 438.60 Prohibition of additional payments for services covered under MCO, PIHP or PAHP contracts. | |
| 42:4.0.1.1.8.2.100.7 | SECTION 438.62
| 438.62 Continued services to enrollees. | |
| 42:4.0.1.1.8.2.100.8 | SECTION 438.66
| 438.66 State monitoring requirements. | |
| 42:4.0.1.1.8.2.100.9 | SECTION 438.68
| 438.68 Network adequacy standards. | |
| 42:4.0.1.1.8.2.100.10 | SECTION 438.70
| 438.70 Stakeholder engagement when LTSS is delivered through a managed care program. | |
| 42:4.0.1.1.8.2.100.11 | SECTION 438.71
| 438.71 Beneficiary support system. | |
| 42:4.0.1.1.8.2.100.12 | SECTION 438.74
| 438.74 State oversight of the minimum MLR requirement. | |
| 42:4.0.1.1.8.3 | SUBPART C
| Subpart C - Enrollee Rights and Protections | |
| 42:4.0.1.1.8.3.100.1 | SECTION 438.100
| 438.100 Enrollee rights. | |
| 42:4.0.1.1.8.3.100.2 | SECTION 438.102
| 438.102 Provider-enrollee communications. | |
| 42:4.0.1.1.8.3.100.3 | SECTION 438.104
| 438.104 Marketing activities. | |
| 42:4.0.1.1.8.3.100.4 | SECTION 438.106
| 438.106 Liability for payment. | |
| 42:4.0.1.1.8.3.100.5 | SECTION 438.108
| 438.108 Cost sharing. | |
| 42:4.0.1.1.8.3.100.6 | SECTION 438.110
| 438.110 Member advisory committee. | |
| 42:4.0.1.1.8.3.100.7 | SECTION 438.114
| 438.114 Emergency and poststabilization services. | |
| 42:4.0.1.1.8.3.100.8 | SECTION 438.116
| 438.116 Solvency standards. | |
| 42:4.0.1.1.8.4 | SUBPART D
| Subpart D - MCO, PIHP and PAHP Standards | |
| 42:4.0.1.1.8.4.100.1 | SECTION 438.206
| 438.206 Availability of services. | |
| 42:4.0.1.1.8.4.100.2 | SECTION 438.207
| 438.207 Assurances of adequate capacity and services. | |
| 42:4.0.1.1.8.4.100.3 | SECTION 438.208
| 438.208 Coordination and continuity of care. | |
| 42:4.0.1.1.8.4.100.4 | SECTION 438.210
| 438.210 Coverage and authorization of services. | |
| 42:4.0.1.1.8.4.100.5 | SECTION 438.214
| 438.214 Provider selection. | |
| 42:4.0.1.1.8.4.100.6 | SECTION 438.224
| 438.224 Confidentiality. | |
| 42:4.0.1.1.8.4.100.7 | SECTION 438.228
| 438.228 Grievance and appeal systems. | |
| 42:4.0.1.1.8.4.100.8 | SECTION 438.230
| 438.230 Subcontractual relationships and delegation. | |
| 42:4.0.1.1.8.4.100.9 | SECTION 438.236
| 438.236 Practice guidelines. | |
| 42:4.0.1.1.8.4.100.10 | SECTION 438.242
| 438.242 Health information systems. | |
| 42:4.0.1.1.8.5 | SUBPART E
| Subpart E - Quality Measurement and Improvement; External Quality Review | |
| 42:4.0.1.1.8.5.100.1 | SECTION 438.310
| 438.310 Basis, scope, and applicability. | |
| 42:4.0.1.1.8.5.100.2 | SECTION 438.320
| 438.320 Definitions. | |
| 42:4.0.1.1.8.5.100.3 | SECTION 438.330
| 438.330 Quality assessment and performance improvement program. | |
| 42:4.0.1.1.8.5.100.4 | SECTION 438.332
| 438.332 State review of the accreditation status of MCOs, PIHPs, and PAHPs. | |
| 42:4.0.1.1.8.5.100.5 | SECTION 438.334
| 438.334 Medicaid managed care quality rating system. | |
| 42:4.0.1.1.8.5.100.6 | SECTION 438.340
| 438.340 Managed care State quality strategy. | |
| 42:4.0.1.1.8.5.100.7 | SECTION 438.350
| 438.350 External quality review. | |
| 42:4.0.1.1.8.5.100.8 | SECTION 438.352
| 438.352 External quality review protocols. | |
| 42:4.0.1.1.8.5.100.9 | SECTION 438.354
| 438.354 Qualifications of external quality review organizations. | |
| 42:4.0.1.1.8.5.100.10 | SECTION 438.356
| 438.356 State contract options for external quality review. | |
| 42:4.0.1.1.8.5.100.11 | SECTION 438.358
| 438.358 Activities related to external quality review. | |
| 42:4.0.1.1.8.5.100.12 | SECTION 438.360
| 438.360 Nonduplication of mandatory activities with Medicare or accreditation review. | |
| 42:4.0.1.1.8.5.100.13 | SECTION 438.362
| 438.362 Exemption from external quality review. | |
| 42:4.0.1.1.8.5.100.14 | SECTION 438.364
| 438.364 External quality review results. | |
| 42:4.0.1.1.8.5.100.15 | SECTION 438.370
| 438.370 Federal financial participation (FFP). | |
| 42:4.0.1.1.8.6 | SUBPART F
| Subpart F - Grievance and Appeal System | |
| 42:4.0.1.1.8.6.100.1 | SECTION 438.400
| 438.400 Statutory basis, definitions, and applicability. | |
| 42:4.0.1.1.8.6.100.2 | SECTION 438.402
| 438.402 General requirements. | |
| 42:4.0.1.1.8.6.100.3 | SECTION 438.404
| 438.404 Timely and adequate notice of adverse benefit determination. | |
| 42:4.0.1.1.8.6.100.4 | SECTION 438.406
| 438.406 Handling of grievances and appeals. | |
| 42:4.0.1.1.8.6.100.5 | SECTION 438.408
| 438.408 Resolution and notification: Grievances and appeals. | |
| 42:4.0.1.1.8.6.100.6 | SECTION 438.410
| 438.410 Expedited resolution of appeals. | |
| 42:4.0.1.1.8.6.100.7 | SECTION 438.414
| 438.414 Information about the grievance and appeal system to providers and subcontractors. | |
| 42:4.0.1.1.8.6.100.8 | SECTION 438.416
| 438.416 Recordkeeping requirements. | |
| 42:4.0.1.1.8.6.100.9 | SECTION 438.420
| 438.420 Continuation of benefits while the MCO, PIHP, or PAHP appeal and the State fair hearing are pending. | |
| 42:4.0.1.1.8.6.100.10 | SECTION 438.424
| 438.424 Effectuation of reversed appeal resolutions. | |
| 42:4.0.1.1.8.7 | SUBPART G
| Subpart G [Reserved] | |
| 42:4.0.1.1.8.8 | SUBPART H
| Subpart H - Additional Program Integrity Safeguards | |
| 42:4.0.1.1.8.8.100.1 | SECTION 438.600
| 438.600 Statutory basis, basic rule, and applicability. | |
| 42:4.0.1.1.8.8.100.2 | SECTION 438.602
| 438.602 State responsibilities. | |
| 42:4.0.1.1.8.8.100.3 | SECTION 438.604
| 438.604 Data, information, and documentation that must be submitted. | |
| 42:4.0.1.1.8.8.100.4 | SECTION 438.606
| 438.606 Source, content, and timing of certification. | |
| 42:4.0.1.1.8.8.100.5 | SECTION 438.608
| 438.608 Program integrity requirements under the contract. | |
| 42:4.0.1.1.8.8.100.6 | SECTION 438.610
| 438.610 Prohibited affiliations. | |
| 42:4.0.1.1.8.9 | SUBPART I
| Subpart I - Sanctions | |
| 42:4.0.1.1.8.9.100.1 | SECTION 438.700
| 438.700 Basis for imposition of sanctions. | |
| 42:4.0.1.1.8.9.100.2 | SECTION 438.702
| 438.702 Types of intermediate sanctions. | |
| 42:4.0.1.1.8.9.100.3 | SECTION 438.704
| 438.704 Amounts of civil money penalties. | |
| 42:4.0.1.1.8.9.100.4 | SECTION 438.706
| 438.706 Special rules for temporary management. | |
| 42:4.0.1.1.8.9.100.5 | SECTION 438.708
| 438.708 Termination of an MCO, PCCM or PCCM entity contract. | |
| 42:4.0.1.1.8.9.100.6 | SECTION 438.710
| 438.710 Notice of sanction and pre-termination hearing. | |
| 42:4.0.1.1.8.9.100.7 | SECTION 438.722
| 438.722 Disenrollment during termination hearing process. | |
| 42:4.0.1.1.8.9.100.8 | SECTION 438.724
| 438.724 Notice to CMS. | |
| 42:4.0.1.1.8.9.100.9 | SECTION 438.726
| 438.726 State plan requirement. | |
| 42:4.0.1.1.8.9.100.10 | SECTION 438.730
| 438.730 Sanction by CMS: Special rules for MCOs. | |
| 42:4.0.1.1.8.10 | SUBPART J
| Subpart J - Conditions for Federal Financial Participation (FFP) | |
| 42:4.0.1.1.8.10.100.1 | SECTION 438.802
| 438.802 Basic requirements. | |
| 42:4.0.1.1.8.10.100.2 | SECTION 438.806
| 438.806 Prior approval. | |
| 42:4.0.1.1.8.10.100.3 | SECTION 438.808
| 438.808 Exclusion of entities. | |
| 42:4.0.1.1.8.10.100.4 | SECTION 438.810
| 438.810 Expenditures for enrollment broker services. | |
| 42:4.0.1.1.8.10.100.5 | SECTION 438.812
| 438.812 Costs under risk and nonrisk contracts. | |
| 42:4.0.1.1.8.10.100.6 | SECTION 438.816
| 438.816 Expenditures for the beneficiary support system for enrollees using LTSS. | |
| 42:4.0.1.1.8.10.100.7 | SECTION 438.818
| 438.818 Enrollee encounter data. | |
| 42:4.0.1.1.8.11 | SUBPART K
| Subpart K - Parity in Mental Health and Substance Use Disorder Benefits | |
| 42:4.0.1.1.8.11.100.1 | SECTION 438.900
| 438.900 Meaning of terms. | |
| 42:4.0.1.1.8.11.100.2 | SECTION 438.905
| 438.905 Parity requirements for aggregate lifetime and annual dollar limits. | |
| 42:4.0.1.1.8.11.100.3 | SECTION 438.910
| 438.910 Parity requirements for financial requirements and treatment limitations. | |
| 42:4.0.1.1.8.11.100.4 | SECTION 438.915
| 438.915 Availability of information. | |
| 42:4.0.1.1.8.11.100.5 | SECTION 438.920
| 438.920 Applicability. | |
| 42:4.0.1.1.8.11.100.6 | SECTION 438.930
| 438.930 Compliance dates. | |
| 42:4.0.1.1.9 | PART 440
| PART 440 - SERVICES: GENERAL PROVISIONS | |
| 42:4.0.1.1.9.1 | SUBPART A
| Subpart A - Definitions | |
| 42:4.0.1.1.9.1.100.1 | SECTION 440.1
| 440.1 Basis and purpose. | |
| 42:4.0.1.1.9.1.100.2 | SECTION 440.2
| 440.2 Specific definitions; definitions of services for FFP purposes. | |
| 42:4.0.1.1.9.1.100.3 | SECTION 440.10
| 440.10 Inpatient hospital services, other than services in an institution for mental diseases. | |
| 42:4.0.1.1.9.1.100.4 | SECTION 440.20
| 440.20 Outpatient hospital services and rural health clinic services. | |
| 42:4.0.1.1.9.1.100.5 | SECTION 440.30
| 440.30 Other laboratory and X-ray services. | |
| 42:4.0.1.1.9.1.100.6 | SECTION 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. | |
| 42:4.0.1.1.9.1.100.7 | SECTION 440.50
| 440.50 Physicians' services and medical and surgical services of a dentist. | |
| 42:4.0.1.1.9.1.100.8 | SECTION 440.60
| 440.60 Medical or other remedial care provided by licensed practitioners. | |
| 42:4.0.1.1.9.1.100.9 | SECTION 440.70
| 440.70 Home health services. | |
| 42:4.0.1.1.9.1.100.10 | SECTION 440.80
| 440.80 Private duty nursing services. | |
| 42:4.0.1.1.9.1.100.11 | SECTION 440.90
| 440.90 Clinic services. | |
| 42:4.0.1.1.9.1.100.12 | SECTION 440.100
| 440.100 Dental services. | |
| 42:4.0.1.1.9.1.100.13 | SECTION 440.110
| 440.110 Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders. | |
| 42:4.0.1.1.9.1.100.14 | SECTION 440.120
| 440.120 Prescribed drugs, dentures, prosthetic devices, and eyeglasses. | |
| 42:4.0.1.1.9.1.100.15 | SECTION 440.130
| 440.130 Diagnostic, screening, preventive, and rehabilitative services. | |
| 42:4.0.1.1.9.1.100.16 | SECTION 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. | |
| 42:4.0.1.1.9.1.100.17 | SECTION 440.150
| 440.150 Intermediate care facility (ICF/IID) services. | |
| 42:4.0.1.1.9.1.100.18 | SECTION 440.155
| 440.155 Nursing facility services, other than in institutions for mental diseases. | |
| 42:4.0.1.1.9.1.100.19 | SECTION 440.160
| 440.160 Inpatient psychiatric services for individuals under age 21. | |
| 42:4.0.1.1.9.1.100.20 | SECTION 440.165
| 440.165 Nurse-midwife service. | |
| 42:4.0.1.1.9.1.100.21 | SECTION 440.166
| 440.166 Nurse practitioner services. | |
| 42:4.0.1.1.9.1.100.22 | SECTION 440.167
| 440.167 Personal care services. | |
| 42:4.0.1.1.9.1.100.23 | SECTION 440.168
| 440.168 Primary care case management services. | |
| 42:4.0.1.1.9.1.100.24 | SECTION 440.169
| 440.169 Case management services. | |
| 42:4.0.1.1.9.1.100.25 | SECTION 440.170
| 440.170 Any other medical care or remedial care recognized under State law and specified by the Secretary. | |
| 42:4.0.1.1.9.1.100.26 | SECTION 440.180
| 440.180 Home and community-based waiver services. | |
| 42:4.0.1.1.9.1.100.27 | SECTION 440.181
| 440.181 Home and community-based services for individuals age 65 or older. | |
| 42:4.0.1.1.9.1.100.28 | SECTION 440.182
| 440.182 State plan home and community-based services. | |
| 42:4.0.1.1.9.1.100.29 | SECTION 440.185
| 440.185 Respiratory care for ventilator-dependent individuals. | |
| 42:4.0.1.1.9.2 | SUBPART B
| Subpart B - Requirements and Limits Applicable to All Services | |
| 42:4.0.1.1.9.2.100.1 | SECTION 440.200
| 440.200 Basis, purpose, and scope. | |
| 42:4.0.1.1.9.2.100.2 | SECTION 440.210
| 440.210 Required services for the categorically needy. | |
| 42:4.0.1.1.9.2.100.3 | SECTION 440.220
| 440.220 Required services for the medically needy. | |
| 42:4.0.1.1.9.2.100.4 | SECTION 440.225
| 440.225 Optional services. | |
| 42:4.0.1.1.9.2.100.5 | SECTION 440.230
| 440.230 Sufficiency of amount, duration, and scope. | |
| 42:4.0.1.1.9.2.100.6 | SECTION 440.240
| 440.240 Comparability of services for groups. | |
| 42:4.0.1.1.9.2.100.7 | SECTION 440.250
| 440.250 Limits on comparability of services. | |
| 42:4.0.1.1.9.2.100.8 | SECTION 440.255
| 440.255 Limited services available to certain aliens. | |
| 42:4.0.1.1.9.2.100.9 | SECTION 440.260
| 440.260 Methods and standards to assure quality of services. | |
| 42:4.0.1.1.9.2.100.10 | SECTION 440.262
| 440.262 Access and cultural conditions. | |
| 42:4.0.1.1.9.2.100.11 | SECTION 440.270
| 440.270 Religious objections. | |
| 42:4.0.1.1.9.3 | SUBPART C
| Subpart C - Benchmark Benefit and Benchmark-Equivalent Coverage | |
| 42:4.0.1.1.9.3.100.1 | SECTION 440.300
| 440.300 Basis. | |
| 42:4.0.1.1.9.3.100.2 | SECTION 440.305
| 440.305 Scope. | |
| 42:4.0.1.1.9.3.100.3 | SECTION 440.310
| 440.310 Applicability. | |
| 42:4.0.1.1.9.3.100.4 | SECTION 440.315
| 440.315 Exempt individuals. | |
| 42:4.0.1.1.9.3.100.5 | SECTION 440.320
| 440.320 State plan requirements: Optional enrollment for exempt individuals. | |
| 42:4.0.1.1.9.3.100.6 | SECTION 440.325
| 440.325 State plan requirements: Coverage and benefits. | |
| 42:4.0.1.1.9.3.100.7 | SECTION 440.330
| 440.330 Benchmark health benefits coverage. | |
| 42:4.0.1.1.9.3.100.8 | SECTION 440.335
| 440.335 Benchmark-equivalent health benefits coverage. | |
| 42:4.0.1.1.9.3.100.9 | SECTION 440.340
| 440.340 Actuarial report for benchmark-equivalent coverage. | |
| 42:4.0.1.1.9.3.100.10 | SECTION 440.345
| 440.345 EPSDT and other required benefits. | |
| 42:4.0.1.1.9.3.100.11 | SECTION 440.347
| 440.347 Essential health benefits. | |
| 42:4.0.1.1.9.3.100.12 | SECTION 440.350
| 440.350 Employer-sponsored insurance health plans. | |
| 42:4.0.1.1.9.3.100.13 | SECTION 440.355
| 440.355 Payment of premiums. | |
| 42:4.0.1.1.9.3.100.14 | SECTION 440.360
| 440.360 State plan requirements for providing additional services. | |
| 42:4.0.1.1.9.3.100.15 | SECTION 440.365
| 440.365 Coverage of rural health clinic and federally qualified health center (FQHC) services. | |
| 42:4.0.1.1.9.3.100.16 | SECTION 440.370
| 440.370 Economy and efficiency. | |
| 42:4.0.1.1.9.3.100.17 | SECTION 440.375
| 440.375 Comparability. | |
| 42:4.0.1.1.9.3.100.18 | SECTION 440.380
| 440.380 Statewideness. | |
| 42:4.0.1.1.9.3.100.19 | SECTION 440.385
| 440.385 Delivery of benchmark and benchmark-equivalent coverage through managed care entities. | |
| 42:4.0.1.1.9.3.100.20 | SECTION 440.386
| 440.386 Public notice. | |
| 42:4.0.1.1.9.3.100.21 | SECTION 440.390
| 440.390 Assurance of transportation. | |
| 42:4.0.1.1.9.3.100.22 | SECTION 440.395
| 440.395 Parity in mental health and substance use disorder benefits. | |
| 42:4.0.1.1.10 | PART 441
| PART 441 - SERVICES: REQUIREMENTS AND LIMITS APPLICABLE TO SPECIFIC SERVICES | |
| 42:4.0.1.1.10.0.100.1 | SECTION 441.1
| 441.1 Purpose. | |
| 42:4.0.1.1.10.1 | SUBPART A
| Subpart A - General Provisions | |
| 42:4.0.1.1.10.1.100.1 | SECTION 441.10
| 441.10 Basis. | |
| 42:4.0.1.1.10.1.100.2 | SECTION 441.11
| 441.11 Continuation of FFP for institutional services. | |
| 42:4.0.1.1.10.1.100.3 | SECTION 441.12
| 441.12 Inpatient hospital tests. | |
| 42:4.0.1.1.10.1.100.4 | SECTION 441.13
| 441.13 Prohibitions on FFP: Institutionalized individuals. | |
| 42:4.0.1.1.10.1.100.5 | SECTION 441.15
| 441.15 Home health services. | |
| 42:4.0.1.1.10.1.100.6 | SECTION 441.16
| 441.16 Home health agency requirements for surety bonds; Prohibition on FFP. | |
| 42:4.0.1.1.10.1.100.7 | SECTION 441.17
| 441.17 Laboratory services. | |
| 42:4.0.1.1.10.1.100.8 | SECTION 441.18
| 441.18 Case management services. | |
| 42:4.0.1.1.10.1.100.9 | SECTION 441.20
| 441.20 Family planning services. | |
| 42:4.0.1.1.10.1.100.10 | SECTION 441.21
| 441.21 Nurse-midwife services. | |
| 42:4.0.1.1.10.1.100.11 | SECTION 441.22
| 441.22 Nurse practitioner services. | |
| 42:4.0.1.1.10.1.100.12 | SECTION 441.25
| 441.25 Prohibition on FFP for certain prescribed drugs. | |
| 42:4.0.1.1.10.1.100.13 | SECTION 441.30
| 441.30 Optometric services. | |
| 42:4.0.1.1.10.1.100.14 | SECTION 441.35
| 441.35 Organ transplants. | |
| 42:4.0.1.1.10.1.100.15 | SECTION 441.40
| 441.40 End-stage renal disease. | |
| 42:4.0.1.1.10.2 | SUBPART B
| Subpart B - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21 | |
| 42:4.0.1.1.10.2.100.1 | SECTION 441.50
| 441.50 Basis and purpose. | |
| 42:4.0.1.1.10.2.100.2 | SECTION 441.55
| 441.55 State plan requirements. | |
| 42:4.0.1.1.10.2.100.3 | SECTION 441.56
| 441.56 Required activities. | |
| 42:4.0.1.1.10.2.100.4 | SECTION 441.57
| 441.57 Discretionary services. | |
| 42:4.0.1.1.10.2.100.5 | SECTION 441.58
| 441.58 Periodicity schedule. | |
| 42:4.0.1.1.10.2.100.6 | SECTION 441.59
| 441.59 Treatment of requests for EPSDT screening services. | |
| 42:4.0.1.1.10.2.100.7 | SECTION 441.60
| 441.60 Continuing care. | |
| 42:4.0.1.1.10.2.100.8 | SECTION 441.61
| 441.61 Utilization of providers and coordination with related programs. | |
| 42:4.0.1.1.10.2.100.9 | SECTION 441.62
| 441.62 Transportation and scheduling assistance. | |
| 42:4.0.1.1.10.3 | SUBPART C
| Subpart C - Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases | |
| 42:4.0.1.1.10.3.100.1 | SECTION 441.100
| 441.100 Basis and purpose. | |
| 42:4.0.1.1.10.3.100.2 | SECTION 441.101
| 441.101 State plan requirements. | |
| 42:4.0.1.1.10.3.100.3 | SECTION 441.102
| 441.102 Plan of care for institutionalized beneficiaries. | |
| 42:4.0.1.1.10.3.100.4 | SECTION 441.103
| 441.103 Alternate plans of care. | |
| 42:4.0.1.1.10.3.100.5 | SECTION 441.105
| 441.105 Methods of administration. | |
| 42:4.0.1.1.10.3.100.6 | SECTION 441.106
| 441.106 Comprehensive mental health program. | |
| 42:4.0.1.1.10.4 | SUBPART D
| Subpart D - Inpatient Psychiatric Services for Individuals Under Age 21 in Psychiatric Facilities or Programs | |
| 42:4.0.1.1.10.4.100.1 | SECTION 441.150
| 441.150 Basis and purpose. | |
| 42:4.0.1.1.10.4.100.2 | SECTION 441.151
| 441.151 General requirements. | |
| 42:4.0.1.1.10.4.100.3 | SECTION 441.152
| 441.152 Certification of need for services. | |
| 42:4.0.1.1.10.4.100.4 | SECTION 441.153
| 441.153 Team certifying need for services. | |
| 42:4.0.1.1.10.4.100.5 | SECTION 441.154
| 441.154 Active treatment. | |
| 42:4.0.1.1.10.4.100.6 | SECTION 441.155
| 441.155 Individual plan of care. | |
| 42:4.0.1.1.10.4.100.7 | SECTION 441.156
| 441.156 Team developing individual plan of care. | |
| 42:4.0.1.1.10.4.100.8 | SECTION 441.180
| 441.180 Maintenance of effort: General rule. | |
| 42:4.0.1.1.10.4.100.9 | SECTION 441.181
| 441.181 Maintenance of effort: Explanation of terms and requirements. | |
| 42:4.0.1.1.10.4.100.10 | SECTION 441.182
| 441.182 Maintenance of effort: Computation. | |
| 42:4.0.1.1.10.4.100.11 | SECTION 441.184
| 441.184 Emergency preparedness. | |
| 42:4.0.1.1.10.5 | SUBPART E
| Subpart E - Abortions | |
| 42:4.0.1.1.10.5.100.1 | SECTION 441.200
| 441.200 Basis and purpose. | |
| 42:4.0.1.1.10.5.100.2 | SECTION 441.201
| 441.201 Definition. | |
| 42:4.0.1.1.10.5.100.3 | SECTION 441.202
| 441.202 General rule. | |
| 42:4.0.1.1.10.5.100.4 | SECTION 441.203
| 441.203 Life of the mother would be endangered. | |
| 42:4.0.1.1.10.5.100.5 | SECTION 441.204-441.205
| 441.204-441.205 [Reserved] | |
| 42:4.0.1.1.10.5.100.6 | SECTION 441.206
| 441.206 Documentation needed by the Medicaid agency. | |
| 42:4.0.1.1.10.5.100.7 | SECTION 441.207
| 441.207 Drugs and devices and termination of ectopic pregnancies. | |
| 42:4.0.1.1.10.5.100.8 | SECTION 441.208
| 441.208 Recordkeeping requirements. | |
| 42:4.0.1.1.10.6 | SUBPART F
| Subpart F - Sterilizations | |
| 42:4.0.1.1.10.6.100.1 | SECTION 441.250
| 441.250 Applicability. | |
| 42:4.0.1.1.10.6.100.2 | SECTION 441.251
| 441.251 Definitions. | |
| 42:4.0.1.1.10.6.100.3 | SECTION 441.252
| 441.252 State plan requirements. | |
| 42:4.0.1.1.10.6.100.4 | SECTION 441.253
| 441.253 Sterilization of a mentally competent individual aged 21 or older. | |
| 42:4.0.1.1.10.6.100.5 | SECTION 441.254
| 441.254 Mentally incompetent or institutionalized individuals. | |
| 42:4.0.1.1.10.6.100.6 | SECTION 441.255
| 441.255 Sterilization by hysterectomy. | |
| 42:4.0.1.1.10.6.100.7 | SECTION 441.256
| 441.256 Additional condition for Federal financial participation (FFP). | |
| 42:4.0.1.1.10.6.100.8 | SECTION 441.257
| 441.257 Informed consent. | |
| 42:4.0.1.1.10.6.100.9 | SECTION 441.258
| 441.258 Consent form requirements. | |
| 42:4.0.1.1.10.6.100.10 | SECTION 441.259
| 441.259 Review of regulations. | |
| 42:4.0.1.1.10.6.100.11.1 | APPENDIX
| Appendix to Subpart F of Part 441 - Required Consent Form | |
| 42:4.0.1.1.10.7 | SUBPART G
| Subpart G - Home and Community-Based Services: Waiver Requirements | |
| 42:4.0.1.1.10.7.100.1 | SECTION 441.300
| 441.300 Basis and purpose. | |
| 42:4.0.1.1.10.7.100.2 | SECTION 441.301
| 441.301 Contents of request for a waiver. | |
| 42:4.0.1.1.10.7.100.3 | SECTION 441.302
| 441.302 State assurances. | |
| 42:4.0.1.1.10.7.100.4 | SECTION 441.303
| 441.303 Supporting documentation required. | |
| 42:4.0.1.1.10.7.100.5 | SECTION 441.304
| 441.304 Duration, extension, and amendment of a waiver. | |
| 42:4.0.1.1.10.7.100.6 | SECTION 441.305
| 441.305 Replacement of beneficiaries in approved waiver programs. | |
| 42:4.0.1.1.10.7.100.7 | SECTION 441.306
| 441.306 Cooperative arrangements with the Maternal and Child Health program. | |
| 42:4.0.1.1.10.7.100.8 | SECTION 441.307
| 441.307 Notification of a waiver termination. | |
| 42:4.0.1.1.10.7.100.9 | SECTION 441.308
| 441.308 Hearings procedures for waiver terminations. | |
| 42:4.0.1.1.10.7.100.10 | SECTION 441.310
| 441.310 Limits on Federal financial participation (FFP). | |
| 42:4.0.1.1.10.8 | SUBPART H
| Subpart H - Home and Community-Based Services Waivers for Individuals Age 65 or Older: Waiver Requirements | |
| 42:4.0.1.1.10.8.100.1 | SECTION 441.350
| 441.350 Basis and purpose. | |
| 42:4.0.1.1.10.8.100.2 | SECTION 441.351
| 441.351 Contents of a request for a waiver. | |
| 42:4.0.1.1.10.8.100.3 | SECTION 441.352
| 441.352 State assurances. | |
| 42:4.0.1.1.10.8.100.4 | SECTION 441.353
| 441.353 Supporting documentation required. | |
| 42:4.0.1.1.10.8.100.5 | SECTION 441.354
| 441.354 Aggregate projected expenditure limit (APEL). | |
| 42:4.0.1.1.10.8.100.6 | SECTION 441.355
| 441.355 Duration, extension, and amendment of a waiver. | |
| 42:4.0.1.1.10.8.100.7 | SECTION 441.356
| 441.356 Waiver termination. | |
| 42:4.0.1.1.10.8.100.8 | SECTION 441.357
| 441.357 Hearing procedures for waiver denials. | |
| 42:4.0.1.1.10.8.100.9 | SECTION 441.360
| 441.360 Limits on Federal financial participation (FFP). | |
| 42:4.0.1.1.10.8.100.10 | SECTION 441.365
| 441.365 Periodic evaluation, assessment, and review. | |
| 42:4.0.1.1.10.9 | SUBPART I
| Subpart I - Community Supported Living Arrangements Services | |
| 42:4.0.1.1.10.9.100.1 | SECTION 441.400
| 441.400 Basis and purpose. | |
| 42:4.0.1.1.10.9.100.2 | SECTION 441.402
| 441.402 State plan requirements. | |
| 42:4.0.1.1.10.9.100.3 | SECTION 441.404
| 441.404 Minimum protection requirements. | |
| 42:4.0.1.1.10.10 | SUBPART J
| Subpart J - Optional Self-Directed Personal Assistance Services Program | |
| 42:4.0.1.1.10.10.100.1 | SECTION 441.450
| 441.450 Basis, scope, and definitions. | |
| 42:4.0.1.1.10.10.100.2 | SECTION 441.452
| 441.452 Self-direction: General. | |
| 42:4.0.1.1.10.10.100.3 | SECTION 441.454
| 441.454 Use of cash. | |
| 42:4.0.1.1.10.10.100.4 | SECTION 441.456
| 441.456 Voluntary disenrollment. | |
| 42:4.0.1.1.10.10.100.5 | SECTION 441.458
| 441.458 Involuntary disenrollment. | |
| 42:4.0.1.1.10.10.100.6 | SECTION 441.460
| 441.460 Participant living arrangements. | |
| 42:4.0.1.1.10.10.100.7 | SECTION 441.462
| 441.462 Statewideness, comparability and limitations on number served. | |
| 42:4.0.1.1.10.10.100.8 | SECTION 441.464
| 441.464 State assurances. | |
| 42:4.0.1.1.10.10.100.9 | SECTION 441.466
| 441.466 Assessment of need. | |
| 42:4.0.1.1.10.10.100.10 | SECTION 441.468
| 441.468 Service plan elements. | |
| 42:4.0.1.1.10.10.100.11 | SECTION 441.470
| 441.470 Service budget elements. | |
| 42:4.0.1.1.10.10.100.12 | SECTION 441.472
| 441.472 Budget methodology. | |
| 42:4.0.1.1.10.10.100.13 | SECTION 441.474
| 441.474 Quality assurance and improvement plan. | |
| 42:4.0.1.1.10.10.100.14 | SECTION 441.476
| 441.476 Risk management. | |
| 42:4.0.1.1.10.10.100.15 | SECTION 441.478
| 441.478 Qualifications of providers of personal assistance. | |
| 42:4.0.1.1.10.10.100.16 | SECTION 441.480
| 441.480 Use of a representative. | |
| 42:4.0.1.1.10.10.100.17 | SECTION 441.482
| 441.482 Permissible purchases. | |
| 42:4.0.1.1.10.10.100.18 | SECTION 441.484
| 441.484 Financial management services. | |
| 42:4.0.1.1.10.11 | SUBPART K
| Subpart K - Home and Community-Based Attendant Services and Supports State Plan Option (Community First Choice) | |
| 42:4.0.1.1.10.11.100.1 | SECTION 441.500
| 441.500 Basis and scope. | |
| 42:4.0.1.1.10.11.100.2 | SECTION 441.505
| 441.505 Definitions. | |
| 42:4.0.1.1.10.11.100.3 | SECTION 441.510
| 441.510 Eligibility. | |
| 42:4.0.1.1.10.11.100.4 | SECTION 441.515
| 441.515 Statewideness. | |
| 42:4.0.1.1.10.11.100.5 | SECTION 441.520
| 441.520 Included services. | |
| 42:4.0.1.1.10.11.100.6 | SECTION 441.525
| 441.525 Excluded services. | |
| 42:4.0.1.1.10.11.100.7 | SECTION 441.530
| 441.530 Home and Community-Based Setting. | |
| 42:4.0.1.1.10.11.100.8 | SECTION 441.535
| 441.535 Assessment of functional need. | |
| 42:4.0.1.1.10.11.100.9 | SECTION 441.540
| 441.540 Person-centered service plan. | |
| 42:4.0.1.1.10.11.100.10 | SECTION 441.545
| 441.545 Service models. | |
| 42:4.0.1.1.10.11.100.11 | SECTION 441.550
| 441.550 Service plan requirements for self-directed model with service budget. | |
| 42:4.0.1.1.10.11.100.12 | SECTION 441.555
| 441.555 Support system. | |
| 42:4.0.1.1.10.11.100.13 | SECTION 441.560
| 441.560 Service budget requirements. | |
| 42:4.0.1.1.10.11.100.14 | SECTION 441.565
| 441.565 Provider qualifications. | |
| 42:4.0.1.1.10.11.100.15 | SECTION 441.570
| 441.570 State assurances. | |
| 42:4.0.1.1.10.11.100.16 | SECTION 441.575
| 441.575 Development and Implementation Council. | |
| 42:4.0.1.1.10.11.100.17 | SECTION 441.580
| 441.580 Data collection. | |
| 42:4.0.1.1.10.11.100.18 | SECTION 441.585
| 441.585 Quality assurance system. | |
| 42:4.0.1.1.10.11.100.19 | SECTION 441.590
| 441.590 Increased Federal financial participation. | |
| 42:4.0.1.1.10.12 | SUBPART L
| Subpart L - Vaccines for Children Program | |
| 42:4.0.1.1.10.12.100.1 | SECTION 441.600
| 441.600 Basis and purpose. | |
| 42:4.0.1.1.10.12.100.2 | SECTION 441.605
| 441.605 General requirements. | |
| 42:4.0.1.1.10.12.100.3 | SECTION 441.610
| 441.610 State plan requirements. | |
| 42:4.0.1.1.10.12.100.4 | SECTION 441.615
| 441.615 Administration fee requirements. | |
| 42:4.0.1.1.10.13 | SUBPART M
| Subpart M - State Plan Home and Community-Based Services for the Elderly and Individuals with Disabilities | |
| 42:4.0.1.1.10.13.100.1 | SECTION 441.700
| 441.700 Basis and purpose. | |
| 42:4.0.1.1.10.13.100.2 | SECTION 441.705
| 441.705 State plan requirements. | |
| 42:4.0.1.1.10.13.100.3 | SECTION 441.710
| 441.710 State plan home and community-based services under section 1915(i)(1) of the Act. | |
| 42:4.0.1.1.10.13.100.4 | SECTION 441.715
| 441.715 Needs-based criteria and evaluation. | |
| 42:4.0.1.1.10.13.100.5 | SECTION 441.720
| 441.720 Independent assessment. | |
| 42:4.0.1.1.10.13.100.6 | SECTION 441.725
| 441.725 Person-centered service plan. | |
| 42:4.0.1.1.10.13.100.7 | SECTION 441.730
| 441.730 Provider qualifications. | |
| 42:4.0.1.1.10.13.100.8 | SECTION 441.735
| 441.735 Definition of individual's representative. | |
| 42:4.0.1.1.10.13.100.9 | SECTION 441.740
| 441.740 Self-directed services. | |
| 42:4.0.1.1.10.13.100.10 | SECTION 441.745
| 441.745 State plan HCBS administration: State responsibilities and quality improvement. | |
| 42:4.0.1.1.11 | PART 442
| PART 442 - STANDARDS FOR PAYMENT TO NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES | |
| 42:4.0.1.1.11.1 | SUBPART A
| Subpart A - General Provisions | |
| 42:4.0.1.1.11.1.100.1 | SECTION 442.1
| 442.1 Basis and purpose. | |
| 42:4.0.1.1.11.1.100.2 | SECTION 442.2
| 442.2 Terms. | |
| 42:4.0.1.1.11.2 | SUBPART B
| Subpart B - Provider Agreements | |
| 42:4.0.1.1.11.2.100.1 | SECTION 442.10
| 442.10 State plan requirement. | |
| 42:4.0.1.1.11.2.100.2 | SECTION 442.12
| 442.12 Provider agreement: General requirements. | |
| 42:4.0.1.1.11.2.100.3 | SECTION 442.13
| 442.13 Effective date of provider agreement. | |
| 42:4.0.1.1.11.2.100.4 | SECTION 442.14
| 442.14 Effect of change of ownership. | |
| 42:4.0.1.1.11.2.100.5 | SECTION 442.15
| 442.15 Duration of agreement for ICF/IIDs. | |
| 42:4.0.1.1.11.2.100.6 | SECTION 442.16
| 442.16 [Reserved] | |
| 42:4.0.1.1.11.2.100.7 | SECTION 442.30
| 442.30 Agreement as evidence of certification. | |
| 42:4.0.1.1.11.2.100.8 | SECTION 442.40
| 442.40 Availability of FFP during appeals for ICFs/IID. | |
| 42:4.0.1.1.11.2.100.9 | SECTION 442.42
| 442.42 FFP under a retroactive provider agreement following appeal. | |
| 42:4.0.1.1.11.3 | SUBPART C
| Subpart C - Certification of ICFs/IID | |
| 42:4.0.1.1.11.3.100.1 | SECTION 442.100
| 442.100 State plan requirements. | |
| 42:4.0.1.1.11.3.100.2 | SECTION 442.101
| 442.101 Obtaining certification. | |
| 42:4.0.1.1.11.3.100.3 | SECTION 442.105
| 442.105 [Reserved] | |
| 42:4.0.1.1.11.3.100.4 | SECTION 442.109
| 442.109 Certification period for ICF/IIDs: General provisions. | |
| 42:4.0.1.1.11.3.100.5 | SECTION 442.110
| 442.110 Certification period for ICF/IID with standard-level deficiencies. | |
| 42:4.0.1.1.11.3.100.6 | SECTION 442.117
| 442.117 Termination of certification for ICFs/IID whose deficiencies pose immediate jeopardy. | |
| 42:4.0.1.1.11.3.100.7 | SECTION 442.118
| 442.118 Denial of payments for new admissions to an ICF/IID. | |
| 42:4.0.1.1.11.3.100.8 | SECTION 442.119
| 442.119 Duration of denial of payments and subsequent termination of an ICF/IID. | |
| 42:4.0.1.1.11.4 | SUBPART D
| Subparts D-F [Reserved] | |
| 42:4.0.1.1.12 | PART 447
| PART 447 - PAYMENTS FOR SERVICES | |
| 42:4.0.1.1.12.1 | SUBPART A
| Subpart A - Payments: General Provisions | |
| 42:4.0.1.1.12.1.109 | SUBJGRP 109
| Medicaid Premiums and Cost Sharing | |
| 42:4.0.1.1.12.1.109.1 | SECTION 447.1
| 447.1 Purpose. | |
| 42:4.0.1.1.12.1.109.2 | SECTION 447.10
| 447.10 Prohibition against reassignment of provider claims. | |
| 42:4.0.1.1.12.1.109.3 | SECTION 447.15
| 447.15 Acceptance of State payment as payment in full. | |
| 42:4.0.1.1.12.1.109.4 | SECTION 447.20
| 447.20 Provider restrictions: State plan requirements. | |
| 42:4.0.1.1.12.1.109.5 | SECTION 447.21
| 447.21 Reduction of payments to providers. | |
| 42:4.0.1.1.12.1.109.6 | SECTION 447.25
| 447.25 Direct payments to certain beneficiaries for physicians' or dentists' services. | |
| 42:4.0.1.1.12.1.109.7 | SECTION 447.26
| 447.26 Prohibition on payment for provider-preventable conditions. | |
| 42:4.0.1.1.12.1.109.8 | SECTION 447.30
| 447.30 Withholding the Federal share of payments to Medicaid providers to recover Medicare overpayments. | |
| 42:4.0.1.1.12.1.109.9 | SECTION 447.31
| 447.31 Withholding Medicare payments to recover Medicaid overpayments. | |
| 42:4.0.1.1.12.1.109.10 | SECTION 447.40
| 447.40 Payments for reserving beds in institutions. | |
| 42:4.0.1.1.12.1.109.11 | SECTION 447.45
| 447.45 Timely claims payment. | |
| 42:4.0.1.1.12.1.109.12 | SECTION 447.46
| 447.46 Timely claims payment by MCOs. | |
| 42:4.0.1.1.12.1.109.13 | SECTION 447.50
| 447.50 Premiums and cost sharing: Basis and purpose. | |
| 42:4.0.1.1.12.1.109.14 | SECTION 447.51
| 447.51 Definitions. | |
| 42:4.0.1.1.12.1.109.15 | SECTION 447.52
| 447.52 Cost sharing. | |
| 42:4.0.1.1.12.1.109.16 | SECTION 447.53
| 447.53 Cost sharing for drugs. | |
| 42:4.0.1.1.12.1.109.17 | SECTION 447.54
| 447.54 Cost sharing for services furnished in a hospital emergency department. | |
| 42:4.0.1.1.12.1.109.18 | SECTION 447.55
| 447.55 Premiums. | |
| 42:4.0.1.1.12.1.109.19 | SECTION 447.56
| 447.56 Limitations on premiums and cost sharing. | |
| 42:4.0.1.1.12.1.109.20 | SECTION 447.57
| 447.57 Beneficiary and public notice requirements. | |
| 42:4.0.1.1.12.1.109.21 | SECTION 447.88
| 447.88 Options for claiming FFP payment for section 1920A presumptive eligibility medical assistance payments. | |
| 42:4.0.1.1.12.1.109.22 | SECTION 447.90
| 447.90 FFP: Conditions related to pending investigations of credible allegations of fraud against the Medicaid program. | |
| 42:4.0.1.1.12.2 | SUBPART B
| Subpart B - Payment Methods: General Provisions | |
| 42:4.0.1.1.12.2.110.1 | SECTION 447.200
| 447.200 Basis and purpose. | |
| 42:4.0.1.1.12.2.110.2 | SECTION 447.201
| 447.201 State plan requirements. | |
| 42:4.0.1.1.12.2.110.3 | SECTION 447.202
| 447.202 Audits. | |
| 42:4.0.1.1.12.2.110.4 | SECTION 447.203
| 447.203 Documentation of access to care and service payment rates. | |
| 42:4.0.1.1.12.2.110.5 | SECTION 447.204
| 447.204 Medicaid provider participation and public process to inform access to care. | |
| 42:4.0.1.1.12.2.110.6 | SECTION 447.205
| 447.205 Public notice of changes in Statewide methods and standards for setting payment rates. | |
| 42:4.0.1.1.12.3 | SUBPART C
| Subpart C - Payment for Inpatient Hospital and Long-Term Care Facility Services | |
| 42:4.0.1.1.12.3.110 | SUBJGRP 110
| Payment Rates | |
| 42:4.0.1.1.12.3.110.1 | SECTION 447.250
| 447.250 Basis and purpose. | |
| 42:4.0.1.1.12.3.110.2 | SECTION 447.251
| 447.251 Definitions. | |
| 42:4.0.1.1.12.3.110.3 | SECTION 447.252
| 447.252 State plan requirements. | |
| 42:4.0.1.1.12.3.110.4 | SECTION 447.253
| 447.253 Other requirements. | |
| 42:4.0.1.1.12.3.110.5 | SECTION 447.255
| 447.255 Related information. | |
| 42:4.0.1.1.12.3.110.6 | SECTION 447.256
| 447.256 Procedures for CMS action on assurances and State plan amendments. | |
| 42:4.0.1.1.12.3.111 | SUBJGRP 111
| Federal Financial Participation | |
| 42:4.0.1.1.12.3.111.7 | SECTION 447.257
| 447.257 FFP: Conditions relating to institutional reimbursement. | |
| 42:4.0.1.1.12.3.112 | SUBJGRP 112
| Upper Limits | |
| 42:4.0.1.1.12.3.112.8 | SECTION 447.271
| 447.271 Upper limits based on customary charges. | |
| 42:4.0.1.1.12.3.112.9 | SECTION 447.272
| 447.272 Inpatient services: Application of upper payment limits. | |
| 42:4.0.1.1.12.3.113 | SUBJGRP 113
| Swing-Bed Hospitals | |
| 42:4.0.1.1.12.3.113.10 | SECTION 447.280
| 447.280 Hospital providers of NF services (swing-bed hospitals). | |
| 42:4.0.1.1.12.4 | SUBPART D
| Subpart D [Reserved] | |
| 42:4.0.1.1.12.5 | SUBPART E
| Subpart E - Payment Adjustments for Hospitals That Serve a Disproportionate Number of Low-Income Patients | |
| 42:4.0.1.1.12.5.114.1 | SECTION 447.294
| 447.294 Medicaid disproportionate share hospital (DSH) allotment reductions. | |
| 42:4.0.1.1.12.5.114.2 | SECTION 447.295
| 447.295 Hospital-specific disproportionate share hospital payment limit: Determination of individuals without health insurance or other third party coverage. | |
| 42:4.0.1.1.12.5.114.3 | SECTION 447.296
| 447.296 Limitations on aggregate payments for disproportionate share hospitals for the period January 1, 1992 through September 30, 1992. | |
| 42:4.0.1.1.12.5.114.4 | SECTION 447.297
| 447.297 Limitations on aggregate payments for disproportionate share hospitals beginning October 1, 1992. | |
| 42:4.0.1.1.12.5.114.5 | SECTION 447.298
| 447.298 State disproportionate share hospital allotments. | |
| 42:4.0.1.1.12.5.114.6 | SECTION 447.299
| 447.299 Reporting requirements. | |
| 42:4.0.1.1.12.6 | SUBPART F
| Subpart F - Payment Methods for Other Institutional and Noninstitutional Services | |
| 42:4.0.1.1.12.6.114 | SUBJGRP 114
| Outpatient Hospital and Clinic Services | |
| 42:4.0.1.1.12.6.114.1 | SECTION 447.300
| 447.300 Basis and purpose. | |
| 42:4.0.1.1.12.6.114.2 | SECTION 447.302
| 447.302 State plan requirements. | |
| 42:4.0.1.1.12.6.114.3 | SECTION 447.304
| 447.304 Adherence to upper limits; FFP. | |
| 42:4.0.1.1.12.6.114.4 | SECTION 447.321
| 447.321 Outpatient hospital and clinic services: Application of upper payment limits. | |
| 42:4.0.1.1.12.6.115 | SUBJGRP 115
| Other Inpatient and Outpatient Facilities | |
| 42:4.0.1.1.12.6.115.5 | SECTION 447.325
| 447.325 Other inpatient and outpatient facility services: Upper limits of payment. | |
| 42:4.0.1.1.12.6.115.6 | SECTION 447.342
| 447.342 [Reserved] | |
| 42:4.0.1.1.12.6.116 | SUBJGRP 116
| Prepaid Capitation Plans | |
| 42:4.0.1.1.12.6.116.7 | SECTION 447.362
| 447.362 Upper limits of payment: Nonrisk contract. | |
| 42:4.0.1.1.12.6.117 | SUBJGRP 117
| Rural Health Clinic Services | |
| 42:4.0.1.1.12.6.117.8 | SECTION 447.371
| 447.371 Services furnished by rural health clinics. | |
| 42:4.0.1.1.12.7 | SUBPART G
| Subpart G - Payments for Primary Care Services Furnished by Physicians | |
| 42:4.0.1.1.12.7.118.1 | SECTION 447.400
| 447.400 Primary care services furnished by physicians with a specified specialty or subspecialty. | |
| 42:4.0.1.1.12.7.118.2 | SECTION 447.405
| 447.405 Amount of required minimum payments. | |
| 42:4.0.1.1.12.7.118.3 | SECTION 447.410
| 447.410 State plan requirements. | |
| 42:4.0.1.1.12.7.118.4 | SECTION 447.415
| 447.415 Availability of Federal financial participation (FFP). | |
| 42:4.0.1.1.12.8 | SUBPART H
| Subpart H [Reserved] | |
| 42:4.0.1.1.12.9 | SUBPART I
| Subpart I - Payment for Drugs | |
| 42:4.0.1.1.12.9.118.1 | SECTION 447.500
| 447.500 Basis and purpose. | |
| 42:4.0.1.1.12.9.118.2 | SECTION 447.502
| 447.502 Definitions. | |
| 42:4.0.1.1.12.9.118.3 | SECTION 447.504
| 447.504 Determination of average manufacturer price. | |
| 42:4.0.1.1.12.9.118.4 | SECTION 447.505
| 447.505 Determination of best price. | |
| 42:4.0.1.1.12.9.118.5 | SECTION 447.506
| 447.506 Authorized generic drugs. | |
| 42:4.0.1.1.12.9.118.6 | SECTION 447.507
| 447.507 Identification of inhalation, infusion, instilled, implanted, or injectable drugs (5i drugs). | |
| 42:4.0.1.1.12.9.118.7 | SECTION 447.508
| 447.508 Exclusion from best price of certain sales at a nominal price. | |
| 42:4.0.1.1.12.9.118.8 | SECTION 447.509
| 447.509 Medicaid drug rebates (MDR). | |
| 42:4.0.1.1.12.9.118.9 | SECTION 447.510
| 447.510 Requirements for manufacturers. | |
| 42:4.0.1.1.12.9.118.10 | SECTION 447.511
| 447.511 Requirements for States. | |
| 42:4.0.1.1.12.9.118.11 | SECTION 447.512
| 447.512 Drugs: Aggregate upper limits of payment. | |
| 42:4.0.1.1.12.9.118.12 | SECTION 447.514
| 447.514 Upper limits for multiple source drugs. | |
| 42:4.0.1.1.12.9.118.13 | SECTION 447.516
| 447.516 Upper limits for drugs furnished as part of services. | |
| 42:4.0.1.1.12.9.118.14 | SECTION 447.518
| 447.518 State plan requirements, findings, and assurances. | |
| 42:4.0.1.1.12.9.118.15 | SECTION 447.520
| 447.520 Federal Financial Participation (FFP): Conditions relating to physician-administered drugs. | |
| 42:4.0.1.1.12.9.118.16 | SECTION 447.522
| 447.522 Optional coverage of investigational drugs and other drugs not subject to rebate. | |
| 42:4.0.1.1.13 | PART 455
| PART 455 - PROGRAM INTEGRITY: MEDICAID | |
| 42:4.0.1.1.13.0.118.1 | SECTION 455.1
| 455.1 Basis and scope. | |
| 42:4.0.1.1.13.0.118.2 | SECTION 455.2
| 455.2 Definitions. | |
| 42:4.0.1.1.13.0.118.3 | SECTION 455.3
| 455.3 Other applicable regulations. | |
| 42:4.0.1.1.13.1 | SUBPART A
| Subpart A - Medicaid Agency Fraud Detection and Investigation Program | |
| 42:4.0.1.1.13.1.118.1 | SECTION 455.12
| 455.12 State plan requirement. | |
| 42:4.0.1.1.13.1.118.2 | SECTION 455.13
| 455.13 Methods for identification, investigation, and referral. | |
| 42:4.0.1.1.13.1.118.3 | SECTION 455.14
| 455.14 Preliminary investigation. | |
| 42:4.0.1.1.13.1.118.4 | SECTION 455.15
| 455.15 Full investigation. | |
| 42:4.0.1.1.13.1.118.5 | SECTION 455.16
| 455.16 Resolution of full investigation. | |
| 42:4.0.1.1.13.1.118.6 | SECTION 455.17
| 455.17 Reporting requirements. | |
| 42:4.0.1.1.13.1.118.7 | SECTION 455.18
| 455.18 Provider's statements on claims forms. | |
| 42:4.0.1.1.13.1.118.8 | SECTION 455.19
| 455.19 Provider's statement on check. | |
| 42:4.0.1.1.13.1.118.9 | SECTION 455.20
| 455.20 Beneficiary verification procedure. | |
| 42:4.0.1.1.13.1.118.10 | SECTION 455.21
| 455.21 Cooperation with State Medicaid fraud control units. | |
| 42:4.0.1.1.13.1.118.11 | SECTION 455.23
| 455.23 Suspension of payments in cases of fraud. | |
| 42:4.0.1.1.13.2 | SUBPART B
| Subpart B - Disclosure of Information by Providers and Fiscal Agents | |
| 42:4.0.1.1.13.2.118.1 | SECTION 455.100
| 455.100 Purpose. | |
| 42:4.0.1.1.13.2.118.2 | SECTION 455.101
| 455.101 Definitions. | |
| 42:4.0.1.1.13.2.118.3 | SECTION 455.102
| 455.102 Determination of ownership or control percentages. | |
| 42:4.0.1.1.13.2.118.4 | SECTION 455.103
| 455.103 State plan requirement. | |
| 42:4.0.1.1.13.2.118.5 | SECTION 455.104
| 455.104 Disclosure by Medicaid providers and fiscal agents: Information on ownership and control. | |
| 42:4.0.1.1.13.2.118.6 | SECTION 455.105
| 455.105 Disclosure by providers: Information related to business transactions. | |
| 42:4.0.1.1.13.2.118.7 | SECTION 455.106
| 455.106 Disclosure by providers: Information on persons convicted of crimes. | |
| 42:4.0.1.1.13.2.118.8 | SECTION 455.107
| 455.107 Disclosure of affiliations. | |
| 42:4.0.1.1.13.3 | SUBPART C
| Subpart C - Medicaid Integrity Program | |
| 42:4.0.1.1.13.3.118.1 | SECTION 455.200
| 455.200 Basis and scope. | |
| 42:4.0.1.1.13.3.118.2 | SECTION 455.202
| 455.202 Limitation on contractor liability. | |
| 42:4.0.1.1.13.3.118.3 | SECTION 455.230
| 455.230 Eligibility requirements. | |
| 42:4.0.1.1.13.3.118.4 | SECTION 455.232
| 455.232 Medicaid integrity audit program contractor functions. | |
| 42:4.0.1.1.13.3.118.5 | SECTION 455.234
| 455.234 Awarding of a contract. | |
| 42:4.0.1.1.13.3.118.6 | SECTION 455.236
| 455.236 Renewal of a contract. | |
| 42:4.0.1.1.13.3.118.7 | SECTION 455.238
| 455.238 Conflict of interest. | |
| 42:4.0.1.1.13.3.118.8 | SECTION 455.240
| 455.240 Conflict of interest resolution. | |
| 42:4.0.1.1.13.4 | SUBPART D
| Subpart D - Independent Certified Audit of State Disproportionate Share Hospital Payment Adjustments | |
| 42:4.0.1.1.13.4.118.1 | SECTION 455.300
| 455.300 Purpose. | |
| 42:4.0.1.1.13.4.118.2 | SECTION 455.301
| 455.301 Definitions. | |
| 42:4.0.1.1.13.4.118.3 | SECTION 455.304
| 455.304 Condition for Federal financial participation (FFP). | |
| 42:4.0.1.1.13.5 | SUBPART E
| Subpart E - Provider Screening and Enrollment | |
| 42:4.0.1.1.13.5.118.1 | SECTION 455.400
| 455.400 Purpose. | |
| 42:4.0.1.1.13.5.118.2 | SECTION 455.405
| 455.405 State plan requirements. | |
| 42:4.0.1.1.13.5.118.3 | SECTION 455.410
| 455.410 Enrollment and screening of providers. | |
| 42:4.0.1.1.13.5.118.4 | SECTION 455.412
| 455.412 Verification of provider licenses. | |
| 42:4.0.1.1.13.5.118.5 | SECTION 455.414
| 455.414 Revalidation of enrollment. | |
| 42:4.0.1.1.13.5.118.6 | SECTION 455.416
| 455.416 Termination or denial of enrollment. | |
| 42:4.0.1.1.13.5.118.7 | SECTION 455.420
| 455.420 Reactivation of provider enrollment. | |
| 42:4.0.1.1.13.5.118.8 | SECTION 455.422
| 455.422 Appeal rights. | |
| 42:4.0.1.1.13.5.118.9 | SECTION 455.432
| 455.432 Site visits. | |
| 42:4.0.1.1.13.5.118.10 | SECTION 455.434
| 455.434 Criminal background checks. | |
| 42:4.0.1.1.13.5.118.11 | SECTION 455.436
| 455.436 Federal database checks. | |
| 42:4.0.1.1.13.5.118.12 | SECTION 455.440
| 455.440 National Provider Identifier. | |
| 42:4.0.1.1.13.5.118.13 | SECTION 455.450
| 455.450 Screening levels for Medicaid providers. | |
| 42:4.0.1.1.13.5.118.14 | SECTION 455.452
| 455.452 Other State screening methods. | |
| 42:4.0.1.1.13.5.118.15 | SECTION 455.460
| 455.460 Application fee. | |
| 42:4.0.1.1.13.5.118.16 | SECTION 455.470
| 455.470 Temporary moratoria. | |
| 42:4.0.1.1.13.6 | SUBPART F
| Subpart F - Medicaid Recovery Audit Contractors Program | |
| 42:4.0.1.1.13.6.118.1 | SECTION 455.500
| 455.500 Purpose. | |
| 42:4.0.1.1.13.6.118.2 | SECTION 455.502
| 455.502 Establishment of program. | |
| 42:4.0.1.1.13.6.118.3 | SECTION 455.504
| 455.504 Definitions. | |
| 42:4.0.1.1.13.6.118.4 | SECTION 455.506
| 455.506 Activities to be conducted by Medicaid RACs and States. | |
| 42:4.0.1.1.13.6.118.5 | SECTION 455.508
| 455.508 Eligibility requirements for Medicaid RACs. | |
| 42:4.0.1.1.13.6.118.6 | SECTION 455.510
| 455.510 Payments to RACs. | |
| 42:4.0.1.1.13.6.118.7 | SECTION 455.512
| 455.512 Medicaid RAC provider appeals. | |
| 42:4.0.1.1.13.6.118.8 | SECTION 455.514
| 455.514 Federal share of State expense of the Medicaid RAC program. | |
| 42:4.0.1.1.13.6.118.9 | SECTION 455.516
| 455.516 Exceptions from Medicaid RAC programs. | |
| 42:4.0.1.1.13.6.118.10 | SECTION 455.518
| 455.518 Applicability to the territories. | |
| 42:4.0.1.1.14 | PART 456
| PART 456 - UTILIZATION CONTROL | |
| 42:4.0.1.1.14.1 | SUBPART A
| Subpart A - General Provisions | |
| 42:4.0.1.1.14.1.143.1 | SECTION 456.1
| 456.1 Basis and purpose of part. | |
| 42:4.0.1.1.14.1.143.2 | SECTION 456.2
| 456.2 State plan requirements. | |
| 42:4.0.1.1.14.1.143.3 | SECTION 456.3
| 456.3 Statewide surveillance and utilization control program. | |
| 42:4.0.1.1.14.1.143.4 | SECTION 456.4
| 456.4 Responsibility for monitoring the utilization control program. | |
| 42:4.0.1.1.14.1.143.5 | SECTION 456.5
| 456.5 Evaluation criteria. | |
| 42:4.0.1.1.14.1.143.6 | SECTION 456.6
| 456.6 Review by State medical agency of appropriateness and quality of services. | |
| 42:4.0.1.1.14.2 | SUBPART B
| Subpart B - Utilization Control: All Medicaid Services | |
| 42:4.0.1.1.14.2.143.1 | SECTION 456.21
| 456.21 Scope. | |
| 42:4.0.1.1.14.2.143.2 | SECTION 456.22
| 456.22 Sample basis evaluation of services. | |
| 42:4.0.1.1.14.2.143.3 | SECTION 456.23
| 456.23 Post-payment review process. | |
| 42:4.0.1.1.14.3 | SUBPART C
| Subpart C - Utilization Control: Hospitals | |
| 42:4.0.1.1.14.3.143 | SUBJGRP 143
| Certification of Need for Care | |
| 42:4.0.1.1.14.3.143.1 | SECTION 456.50
| 456.50 Scope. | |
| 42:4.0.1.1.14.3.143.2 | SECTION 456.51
| 456.51 Definitions. | |
| 42:4.0.1.1.14.3.143.3 | SECTION 456.60
| 456.60 Certification and recertification of need for inpatient care. | |
| 42:4.0.1.1.14.3.144 | SUBJGRP 144
| Plan of Care | |
| 42:4.0.1.1.14.3.144.4 | SECTION 456.80
| 456.80 Individual written plan of care. | |
| 42:4.0.1.1.14.3.145 | SUBJGRP 145
| Utilization Review (UR) Plan: General Requirement | |
| 42:4.0.1.1.14.3.145.5 | SECTION 456.100
| 456.100 Scope. | |
| 42:4.0.1.1.14.3.145.6 | SECTION 456.101
| 456.101 UR plan required for inpatient hospital services. | |
| 42:4.0.1.1.14.3.146 | SUBJGRP 146
| UR Plan: Administrative Requirements | |
| 42:4.0.1.1.14.3.146.7 | SECTION 456.105
| 456.105 UR committee required. | |
| 42:4.0.1.1.14.3.146.8 | SECTION 456.106
| 456.106 Organization and composition of UR committee; disqualification from UR committee membership. | |
| 42:4.0.1.1.14.3.147 | SUBJGRP 147
| UR Plan: Informational Requirements | |
| 42:4.0.1.1.14.3.147.9 | SECTION 456.111
| 456.111 Beneficiary information required for UR. | |
| 42:4.0.1.1.14.3.147.10 | SECTION 456.112
| 456.112 Records and reports. | |
| 42:4.0.1.1.14.3.147.11 | SECTION 456.113
| 456.113 Confidentiality. | |
| 42:4.0.1.1.14.3.148 | SUBJGRP 148
| UR Plan: Review of Need for Admission 1 | |
| 42:4.0.1.1.14.3.148.12 | SECTION 456.121
| 456.121 Admission review required. | |
| 42:4.0.1.1.14.3.148.13 | SECTION 456.122
| 456.122 Evaluation criteria for admission review. | |
| 42:4.0.1.1.14.3.148.14 | SECTION 456.123
| 456.123 Admission review process. | |
| 42:4.0.1.1.14.3.148.15 | SECTION 456.124
| 456.124 Notification of adverse decision. | |
| 42:4.0.1.1.14.3.148.16 | SECTION 456.125
| 456.125 Time limits for admission review. | |
| 42:4.0.1.1.14.3.148.17 | SECTION 456.126
| 456.126 Time limits for final decision and notification of adverse decision. | |
| 42:4.0.1.1.14.3.148.18 | SECTION 456.127
| 456.127 Pre-admission review. | |
| 42:4.0.1.1.14.3.148.19 | SECTION 456.128
| 456.128 Initial continued stay review date. | |
| 42:4.0.1.1.14.3.148.20 | SECTION 456.129
| 456.129 Description of methods and criteria: Initial continued stay review date; close professional scrutiny; length of stay modification. | |
| 42:4.0.1.1.14.3.149 | SUBJGRP 149
| UR Plan: Review of Need for Continued Stay | |
| 42:4.0.1.1.14.3.149.21 | SECTION 456.131
| 456.131 Continued stay review required. | |
| 42:4.0.1.1.14.3.149.22 | SECTION 456.132
| 456.132 Evaluation criteria for continued stay. | |
| 42:4.0.1.1.14.3.149.23 | SECTION 456.133
| 456.133 Subsequent continued stay review dates. | |
| 42:4.0.1.1.14.3.149.24 | SECTION 456.134
| 456.134 Description of methods and criteria: Subsequent continued stay review dates; length of stay modification. | |
| 42:4.0.1.1.14.3.149.25 | SECTION 456.135
| 456.135 Continued stay review process. | |
| 42:4.0.1.1.14.3.149.26 | SECTION 456.136
| 456.136 Notification of adverse decision. | |
| 42:4.0.1.1.14.3.149.27 | SECTION 456.137
| 456.137 Time limits for final decision and notification of adverse decision. | |
| 42:4.0.1.1.14.3.150 | SUBJGRP 150
| UR Plan: Medical Care Evaluation Studies | |
| 42:4.0.1.1.14.3.150.28 | SECTION 456.141
| 456.141 Purpose and general description. | |
| 42:4.0.1.1.14.3.150.29 | SECTION 456.142
| 456.142 UR plan requirements for medical care evaluation studies. | |
| 42:4.0.1.1.14.3.150.30 | SECTION 456.143
| 456.143 Content of medical care evaluation studies. | |
| 42:4.0.1.1.14.3.150.31 | SECTION 456.144
| 456.144 Data sources for studies. | |
| 42:4.0.1.1.14.3.150.32 | SECTION 456.145
| 456.145 Number of studies required to be performed. | |
| 42:4.0.1.1.14.4 | SUBPART D
| Subpart D - Utilization Control: Mental Hospitals | |
| 42:4.0.1.1.14.4.151 | SUBJGRP 151
| Certification of Need for Care | |
| 42:4.0.1.1.14.4.151.1 | SECTION 456.150
| 456.150 Scope. | |
| 42:4.0.1.1.14.4.151.2 | SECTION 456.151
| 456.151 Definitions. | |
| 42:4.0.1.1.14.4.151.3 | SECTION 456.160
| 456.160 Certification and recertification of need for inpatient care. | |
| 42:4.0.1.1.14.4.152 | SUBJGRP 152
| Medical, Psychiatric, and Social Evaluations and Admission Review | |
| 42:4.0.1.1.14.4.152.4 | SECTION 456.170
| 456.170 Medical, psychiatric, and social evaluations. | |
| 42:4.0.1.1.14.4.152.5 | SECTION 456.171
| 456.171 [Reserved] | |
| 42:4.0.1.1.14.4.153 | SUBJGRP 153
| Plan of Care | |
| 42:4.0.1.1.14.4.153.6 | SECTION 456.180
| 456.180 Individual written plan of care. | |
| 42:4.0.1.1.14.4.153.7 | SECTION 456.181
| 456.181 Reports of evaluations and plans of care. | |
| 42:4.0.1.1.14.4.154 | SUBJGRP 154
| Utilization Review (UR) Plan: General Requirements | |
| 42:4.0.1.1.14.4.154.8 | SECTION 456.200
| 456.200 Scope. | |
| 42:4.0.1.1.14.4.154.9 | SECTION 456.201
| 456.201 UR plan required for inpatient mental hospital services. | |
| 42:4.0.1.1.14.4.155 | SUBJGRP 155
| UR Plan: Administrative Requirements | |
| 42:4.0.1.1.14.4.155.10 | SECTION 456.205
| 456.205 UR committee required. | |
| 42:4.0.1.1.14.4.155.11 | SECTION 456.206
| 456.206 Organization and composition of UR committee; disqualification from UR committee membership. | |
| 42:4.0.1.1.14.4.156 | SUBJGRP 156
| UR Plan: Informational Requirements | |
| 42:4.0.1.1.14.4.156.12 | SECTION 456.211
| 456.211 Beneficiary information required for UR. | |
| 42:4.0.1.1.14.4.156.13 | SECTION 456.212
| 456.212 Records and reports. | |
| 42:4.0.1.1.14.4.156.14 | SECTION 456.213
| 456.213 Confidentiality. | |
| 42:4.0.1.1.14.4.157 | SUBJGRP 157
| UR Plan: Review of Need for Continued Stay | |
| 42:4.0.1.1.14.4.157.15 | SECTION 456.231
| 456.231 Continued stay review required. | |
| 42:4.0.1.1.14.4.157.16 | SECTION 456.232
| 456.232 Evaluation criteria for continued stay. | |
| 42:4.0.1.1.14.4.157.17 | SECTION 456.233
| 456.233 Initial continued stay review date. | |
| 42:4.0.1.1.14.4.157.18 | SECTION 456.234
| 456.234 Subsequent continued stay review dates. | |
| 42:4.0.1.1.14.4.157.19 | SECTION 456.235
| 456.235 Description of methods and criteria: Continued stay review dates; length of stay modification. | |
| 42:4.0.1.1.14.4.157.20 | SECTION 456.236
| 456.236 Continued stay review process. | |
| 42:4.0.1.1.14.4.157.21 | SECTION 456.237
| 456.237 Notification of adverse decision. | |
| 42:4.0.1.1.14.4.157.22 | SECTION 456.238
| 456.238 Time limits for final decision and notification of adverse decision. | |
| 42:4.0.1.1.14.4.158 | SUBJGRP 158
| UR Plan: Medical Care Evaluation Studies | |
| 42:4.0.1.1.14.4.158.23 | SECTION 456.241
| 456.241 Purpose and general description. | |
| 42:4.0.1.1.14.4.158.24 | SECTION 456.242
| 456.242 UR plan requirements for medical care evaluation studies. | |
| 42:4.0.1.1.14.4.158.25 | SECTION 456.243
| 456.243 Content of medical care evaluation studies. | |
| 42:4.0.1.1.14.4.158.26 | SECTION 456.244
| 456.244 Data sources for studies. | |
| 42:4.0.1.1.14.4.158.27 | SECTION 456.245
| 456.245 Number of studies required to be performed. | |
| 42:4.0.1.1.14.5 | SUBPART E
| Subpart E [Reserved] | |
| 42:4.0.1.1.14.6 | SUBPART F
| Subpart F - Utilization Control: Intermediate Care Facilities | |
| 42:4.0.1.1.14.6.159 | SUBJGRP 159
| Certification of Need for Care | |
| 42:4.0.1.1.14.6.159.1 | SECTION 456.350
| 456.350 Scope. | |
| 42:4.0.1.1.14.6.159.2 | SECTION 456.351
| 456.351 Definition. | |
| 42:4.0.1.1.14.6.159.3 | SECTION 456.360
| 456.360 Certification and recertification of need for inpatient care. | |
| 42:4.0.1.1.14.6.160 | SUBJGRP 160
| Medical, Psychological, and Social Evaluations and Admission Review | |
| 42:4.0.1.1.14.6.160.4 | SECTION 456.370
| 456.370 Medical, psychological, and social evaluations. | |
| 42:4.0.1.1.14.6.160.5 | SECTION 456.371
| 456.371 Exploration of alternative services. | |
| 42:4.0.1.1.14.6.160.6 | SECTION 456.372
| 456.372 Medicaid agency review of need for admission. | |
| 42:4.0.1.1.14.6.161 | SUBJGRP 161
| Plan of Care | |
| 42:4.0.1.1.14.6.161.7 | SECTION 456.380
| 456.380 Individual written plan of care. | |
| 42:4.0.1.1.14.6.161.8 | SECTION 456.381
| 456.381 Reports of evaluations and plans of care. | |
| 42:4.0.1.1.14.6.162 | SUBJGRP 162
| Utilization Review (UR) Plan: General Requirement | |
| 42:4.0.1.1.14.6.162.9 | SECTION 456.400
| 456.400 Scope. | |
| 42:4.0.1.1.14.6.162.10 | SECTION 456.401
| 456.401 State plan UR requirements and options; UR plan required for intermediate care facility services. | |
| 42:4.0.1.1.14.6.163 | SUBJGRP 163
| UR Plan: Administrative Requirements | |
| 42:4.0.1.1.14.6.163.11 | SECTION 456.405
| 456.405 Description of UR review function: How and when. | |
| 42:4.0.1.1.14.6.163.12 | SECTION 456.406
| 456.406 Description of UR review function: Who performs UR; disqualification from performing UR. | |
| 42:4.0.1.1.14.6.163.13 | SECTION 456.407
| 456.407 UR responsibilities of administrative staff. | |
| 42:4.0.1.1.14.6.164 | SUBJGRP 164
| UR Plan: Informational Requirements | |
| 42:4.0.1.1.14.6.164.14 | SECTION 456.411
| 456.411 Beneficiary information required for UR. | |
| 42:4.0.1.1.14.6.164.15 | SECTION 456.412
| 456.412 Records and reports. | |
| 42:4.0.1.1.14.6.164.16 | SECTION 456.413
| 456.413 Confidentiality. | |
| 42:4.0.1.1.14.6.165 | SUBJGRP 165
| UR Plan: Review of Need for Continued Stay | |
| 42:4.0.1.1.14.6.165.17 | SECTION 456.431
| 456.431 Continued stay review required. | |
| 42:4.0.1.1.14.6.165.18 | SECTION 456.432
| 456.432 Evaluation criteria for continued stay. | |
| 42:4.0.1.1.14.6.165.19 | SECTION 456.433
| 456.433 Initial continued stay review date. | |
| 42:4.0.1.1.14.6.165.20 | SECTION 456.434
| 456.434 Subsequent continued stay review dates. | |
| 42:4.0.1.1.14.6.165.21 | SECTION 456.435
| 456.435 Description of methods and criteria: Continued stay review dates. | |
| 42:4.0.1.1.14.6.165.22 | SECTION 456.436
| 456.436 Continued stay review process. | |
| 42:4.0.1.1.14.6.165.23 | SECTION 456.437
| 456.437 Notification of adverse decision. | |
| 42:4.0.1.1.14.6.165.24 | SECTION 456.438
| 456.438 Time limits for notification of adverse decision. | |
| 42:4.0.1.1.14.7 | SUBPART G
| Subpart G - Inpatient Psychiatric Services for Individuals Under Age 21: Admission and Plan of Care Requirements | |
| 42:4.0.1.1.14.7.166.1 | SECTION 456.480
| 456.480 Scope. | |
| 42:4.0.1.1.14.7.166.2 | SECTION 456.481
| 456.481 Admission certification and plan of care. | |
| 42:4.0.1.1.14.7.166.3 | SECTION 456.482
| 456.482 Medical, psychiatric, and social evaluations. | |
| 42:4.0.1.1.14.8 | SUBPART H
| Subpart H - Utilization Review Plans: FFP, Waivers, and Variances for Hospitals and Mental Hospitals | |
| 42:4.0.1.1.14.8.166 | SUBJGRP 166
| UR Plan: Waiver of Requirements | |
| 42:4.0.1.1.14.8.166.1 | SECTION 456.500
| 456.500 Purpose. | |
| 42:4.0.1.1.14.8.166.2 | SECTION 456.501
| 456.501 UR plans as a condition for FFP. | |
| 42:4.0.1.1.14.8.166.3 | SECTION 456.505
| 456.505 Applicability of waiver. | |
| 42:4.0.1.1.14.8.166.4 | SECTION 456.506
| 456.506 Waiver options for Medicaid agency. | |
| 42:4.0.1.1.14.8.166.5 | SECTION 456.507
| 456.507 Review and granting of waiver requests. | |
| 42:4.0.1.1.14.8.166.6 | SECTION 456.508
| 456.508 Withdrawal of waiver. | |
| 42:4.0.1.1.14.8.167 | SUBJGRP 167
| UR Plan: Remote Facility Variances from Time Requirements | |
| 42:4.0.1.1.14.8.167.7 | SECTION 456.520
| 456.520 Definitions. | |
| 42:4.0.1.1.14.8.167.8 | SECTION 456.521
| 456.521 Conditions for granting variance requests. | |
| 42:4.0.1.1.14.8.167.9 | SECTION 456.522
| 456.522 Content of request for variance. | |
| 42:4.0.1.1.14.8.167.10 | SECTION 456.523
| 456.523 Revised UR plan. | |
| 42:4.0.1.1.14.8.167.11 | SECTION 456.524
| 456.524 Notification of Administrator's action and duration of variance. | |
| 42:4.0.1.1.14.8.167.12 | SECTION 456.525
| 456.525 Request for renewal of variance. | |
| 42:4.0.1.1.14.9 | SUBPART I
| Subpart I - Inspections of Care in Intermediate Care Facilities and Institutions for Mental Diseases | |
| 42:4.0.1.1.14.9.168.1 | SECTION 456.600
| 456.600 Purpose. | |
| 42:4.0.1.1.14.9.168.2 | SECTION 456.601
| 456.601 Definitions. | |
| 42:4.0.1.1.14.9.168.3 | SECTION 456.602
| 456.602 Inspection team. | |
| 42:4.0.1.1.14.9.168.4 | SECTION 456.603
| 456.603 Financial interests and employment of team members. | |
| 42:4.0.1.1.14.9.168.5 | SECTION 456.604
| 456.604 Physician team member inspecting care of beneficiaries. | |
| 42:4.0.1.1.14.9.168.6 | SECTION 456.605
| 456.605 Number and location of teams. | |
| 42:4.0.1.1.14.9.168.7 | SECTION 456.606
| 456.606 Frequency of inspections. | |
| 42:4.0.1.1.14.9.168.8 | SECTION 456.607
| 456.607 Notification before inspection. | |
| 42:4.0.1.1.14.9.168.9 | SECTION 456.608
| 456.608 Personal contact with and observation of beneficiaries and review of records. | |
| 42:4.0.1.1.14.9.168.10 | SECTION 456.609
| 456.609 Determinations by team. | |
| 42:4.0.1.1.14.9.168.11 | SECTION 456.610
| 456.610 Basis for determinations. | |
| 42:4.0.1.1.14.9.168.12 | SECTION 456.611
| 456.611 Reports on inspections. | |
| 42:4.0.1.1.14.9.168.13 | SECTION 456.612
| 456.612 Copies of reports. | |
| 42:4.0.1.1.14.9.168.14 | SECTION 456.613
| 456.613 Action on reports. | |
| 42:4.0.1.1.14.9.168.15 | SECTION 456.614
| 456.614 Inspections by utilization review committee. | |
| 42:4.0.1.1.14.10 | SUBPART J
| Subpart J - Penalty for Failure To Make a Satisfactory Showing of an Effective Institutional Utilization Control Program | |
| 42:4.0.1.1.14.10.168.1 | SECTION 456.650
| 456.650 Basis, purpose and scope. | |
| 42:4.0.1.1.14.10.168.2 | SECTION 456.651
| 456.651 Definitions. | |
| 42:4.0.1.1.14.10.168.3 | SECTION 456.652
| 456.652 Requirements for an effective utilization control program. | |
| 42:4.0.1.1.14.10.168.4 | SECTION 456.653
| 456.653 Acceptable reasons for not meeting requirements for annual on-site review. | |
| 42:4.0.1.1.14.10.168.5 | SECTION 456.654
| 456.654 Requirements for content of showings and procedures for submittal. | |
| 42:4.0.1.1.14.10.168.6 | SECTION 456.655
| 456.655 Validation of showings. | |
| 42:4.0.1.1.14.10.168.7 | SECTION 456.656
| 456.656 Reductions in FFP. | |
| 42:4.0.1.1.14.10.168.8 | SECTION 456.657
| 456.657 Computation of reductions in FFP. | |
| 42:4.0.1.1.14.11 | SUBPART K
| Subpart K - Drug Use Review (DUR) Program and Electronic Claims Management System for Outpatient Drug Claims | |
| 42:4.0.1.1.14.11.168.1 | SECTION 456.700
| 456.700 Scope. | |
| 42:4.0.1.1.14.11.168.2 | SECTION 456.702
| 456.702 Definitions. | |
| 42:4.0.1.1.14.11.168.3 | SECTION 456.703
| 456.703 Drug use review program. | |
| 42:4.0.1.1.14.11.168.4 | SECTION 456.705
| 456.705 Prospective drug review. | |
| 42:4.0.1.1.14.11.168.5 | SECTION 456.709
| 456.709 Retrospective drug use review. | |
| 42:4.0.1.1.14.11.168.6 | SECTION 456.711
| 456.711 Educational program. | |
| 42:4.0.1.1.14.11.168.7 | SECTION 456.712
| 456.712 Annual report. | |
| 42:4.0.1.1.14.11.168.8 | SECTION 456.714
| 456.714 DUR/surveillance and utilization review relationship. | |
| 42:4.0.1.1.14.11.168.9 | SECTION 456.716
| 456.716 DUR Board. | |
| 42:4.0.1.1.14.11.168.10 | SECTION 456.719
| 456.719 Funding for DUR program. | |
| 42:4.0.1.1.14.11.168.11 | SECTION 456.722
| 456.722 Electronic claims management system. | |
| 42:4.0.1.1.14.11.168.12 | SECTION 456.725
| 456.725 Funding of ECM system. | |