Title 42

PART 417

Part 417 - Health Maintenance Organizations, Competitive Medical Plans, And Health Care Prepayment Plans

PART 417 - HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Authority:42 U.S.C. 1302 and 1395hh, and 300e, 300e-5, and 300e-9, and 31 U.S.C. 9701.

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