Title 42

PART 431

Part 431 - State Organization And General Administration

PART 431 - STATE ORGANIZATION AND GENERAL ADMINISTRATION Authority:Sec. 1102 of the Social Security Act, (42 U.S.C. 1302). Link to an amendment published at 85 FR 25634, May 1, 2020. Source:43 FR 45188, Sept. 29, 1978, unless otherwise noted. Editorial Note:Nomenclature changes to part 431 appear at 75 FR 48852, Aug. 11, 2010.

42:4.0.1.1.2.0.8.1SECTION 431.1
   431.1 Purpose.
42:4.0.1.1.2.1SUBPART A
Subpart A - Single State Agency
42:4.0.1.1.2.1.8.1SECTION 431.10
   431.10 Single State agency.
42:4.0.1.1.2.1.8.2SECTION 431.11
   431.11 Organization for administration.
42:4.0.1.1.2.1.8.3SECTION 431.12
   431.12 Medical care advisory committee.
42:4.0.1.1.2.1.8.4SECTION 431.15
   431.15 Methods of administration.
42:4.0.1.1.2.1.8.5SECTION 431.16
   431.16 Reports.
42:4.0.1.1.2.1.8.6SECTION 431.17
   431.17 Maintenance of records.
42:4.0.1.1.2.1.8.7SECTION 431.18
   431.18 Availability of agency program manuals.
42:4.0.1.1.2.1.8.8SECTION 431.20
   431.20 Advance directives.
42:4.0.1.1.2.2SUBPART B
Subpart B - General Administrative Requirements
42:4.0.1.1.2.2.8.1SECTION 431.40
   431.40 Basis and scope.
42:4.0.1.1.2.2.8.2SECTION 431.50
   431.50 Statewide operation.
42:4.0.1.1.2.2.8.3SECTION 431.51
   431.51 Free choice of providers.
42:4.0.1.1.2.2.8.4SECTION 431.52
   431.52 Payments for services furnished out of State.
42:4.0.1.1.2.2.8.5SECTION 431.53
   431.53 Assurance of transportation.
42:4.0.1.1.2.2.8.6SECTION 431.54
   431.54 Exceptions to certain State plan requirements.
42:4.0.1.1.2.2.8.7SECTION 431.55
   431.55 Waiver of other Medicaid requirements.
42:4.0.1.1.2.2.8.8SECTION 431.56
   431.56 Special waiver provisions applicable to American Samoa and the Northern Mariana Islands.
42:4.0.1.1.2.2.8.9SECTION 431.60
   431.60 xxx
42:4.0.1.1.2.2.8.10SECTION 431.70
   431.70 xxx
42:4.0.1.1.2.3SUBPART C
Subpart C - Administrative Requirements: Provider Relations
42:4.0.1.1.2.3.8.1SECTION 431.105
   431.105 Consultation to medical facilities.
42:4.0.1.1.2.3.8.2SECTION 431.107
   431.107 Required provider agreement.
42:4.0.1.1.2.3.8.3SECTION 431.108
   431.108 Effective date of provider agreements.
42:4.0.1.1.2.3.8.4SECTION 431.110
   431.110 Participation by Indian Health Service facilities.
42:4.0.1.1.2.3.8.5SECTION 431.115
   431.115 Disclosure of survey information and provider or contractor evaluation.
42:4.0.1.1.2.3.8.6SECTION 431.120
   431.120 State requirements with respect to nursing facilities.
42:4.0.1.1.2.4SUBPART D
Subpart D - Appeals Process for NFs and ICFs/IID
42:4.0.1.1.2.4.8.1SECTION 431.151
   431.151 Scope and applicability.
42:4.0.1.1.2.4.8.2SECTION 431.152
   431.152 State plan requirements.
42:4.0.1.1.2.4.8.3SECTION 431.153
   431.153 Evidentiary hearing.
42:4.0.1.1.2.4.8.4SECTION 431.154
   431.154 Informal reconsideration for ICFs/IID.
42:4.0.1.1.2.5SUBPART E
Subpart E - Fair Hearings for Applicants and Beneficiaries
42:4.0.1.1.2.5.8SUBJGRP 8
   General Provisions
42:4.0.1.1.2.5.8.1SECTION 431.200
   431.200 Basis and scope.
42:4.0.1.1.2.5.8.2SECTION 431.201
   431.201 Definitions.
42:4.0.1.1.2.5.8.3SECTION 431.202
   431.202 State plan requirements.
42:4.0.1.1.2.5.8.4SECTION 431.205
   431.205 Provision of hearing system.
42:4.0.1.1.2.5.8.5SECTION 431.206
   431.206 Informing applicants and beneficiaries.
42:4.0.1.1.2.5.9SUBJGRP 9
   Notice
42:4.0.1.1.2.5.9.6SECTION 431.210
   431.210 Content of notice.
42:4.0.1.1.2.5.9.7SECTION 431.211
   431.211 Advance notice.
42:4.0.1.1.2.5.9.8SECTION 431.213
   431.213 Exceptions from advance notice.
42:4.0.1.1.2.5.9.9SECTION 431.214
   431.214 Notice in cases of probable fraud.
42:4.0.1.1.2.5.10SUBJGRP 10
   Right to Hearing
42:4.0.1.1.2.5.10.10SECTION 431.220
   431.220 When a hearing is required.
42:4.0.1.1.2.5.10.11SECTION 431.221
   431.221 Request for hearing.
42:4.0.1.1.2.5.10.12SECTION 431.222
   431.222 Group hearings.
42:4.0.1.1.2.5.10.13SECTION 431.223
   431.223 Denial or dismissal of request for a hearing.
42:4.0.1.1.2.5.10.14SECTION 431.224
   431.224 Expedited appeals.
42:4.0.1.1.2.5.11SUBJGRP 11
   Procedures
42:4.0.1.1.2.5.11.15SECTION 431.230
   431.230 Maintaining services.
42:4.0.1.1.2.5.11.16SECTION 431.231
   431.231 Reinstating services.
42:4.0.1.1.2.5.11.17SECTION 431.232
   431.232 Adverse decision of local evidentiary hearing.
42:4.0.1.1.2.5.11.18SECTION 431.233
   431.233 State agency hearing after adverse decision of local evidentiary hearing.
42:4.0.1.1.2.5.11.19SECTION 431.240
   431.240 Conducting the hearing.
42:4.0.1.1.2.5.11.20SECTION 431.241
   431.241 Matters to be considered at the hearing.
42:4.0.1.1.2.5.11.21SECTION 431.242
   431.242 Procedural rights of the applicant or beneficiary.
42:4.0.1.1.2.5.11.22SECTION 431.243
   431.243 Parties in cases involving an eligibility determination.
42:4.0.1.1.2.5.11.23SECTION 431.244
   431.244 Hearing decisions.
42:4.0.1.1.2.5.11.24SECTION 431.245
   431.245 Notifying the applicant or beneficiary of a State agency decision.
42:4.0.1.1.2.5.11.25SECTION 431.246
   431.246 Corrective action.
42:4.0.1.1.2.5.12SUBJGRP 12
   Federal Financial Participation
42:4.0.1.1.2.5.12.26SECTION 431.250
   431.250 Federal financial participation.
42:4.0.1.1.2.6SUBPART F
Subpart F - Safeguarding Information on Applicants and Beneficiaries
42:4.0.1.1.2.6.13.1SECTION 431.300
   431.300 Basis and purpose.
42:4.0.1.1.2.6.13.2SECTION 431.301
   431.301 State plan requirements.
42:4.0.1.1.2.6.13.3SECTION 431.302
   431.302 Purposes directly related to State plan administration.
42:4.0.1.1.2.6.13.4SECTION 431.303
   431.303 State authority for safeguarding information.
42:4.0.1.1.2.6.13.5SECTION 431.304
   431.304 Publicizing safeguarding requirements.
42:4.0.1.1.2.6.13.6SECTION 431.305
   431.305 Types of information to be safeguarded.
42:4.0.1.1.2.6.13.7SECTION 431.306
   431.306 Release of information.
42:4.0.1.1.2.6.13.8SECTION 431.307
   431.307 Distribution of information materials.
42:4.0.1.1.2.7SUBPART G
Subpart G - Section 1115 Demonstrations
42:4.0.1.1.2.7.13.1SECTION 431.400
   431.400 Basis and purpose.
42:4.0.1.1.2.7.13.2SECTION 431.404
   431.404 Definitions.
42:4.0.1.1.2.7.13.3SECTION 431.408
   431.408 State public notice process.
42:4.0.1.1.2.7.13.4SECTION 431.412
   431.412 Application procedures.
42:4.0.1.1.2.7.13.5SECTION 431.416
   431.416 Federal public notice and approval process.
42:4.0.1.1.2.7.13.6SECTION 431.420
   431.420 Monitoring and compliance.
42:4.0.1.1.2.7.13.7SECTION 431.424
   431.424 Evaluation requirements.
42:4.0.1.1.2.7.13.8SECTION 431.428
   431.428 Reporting requirements.
42:4.0.1.1.2.8SUBPART H
Subparts H-L [Reserved]
42:4.0.1.1.2.9SUBPART M
Subpart M - Relations With Other Agencies
42:4.0.1.1.2.9.13.1SECTION 431.610
   431.610 Relations with standard-setting and survey agencies.
42:4.0.1.1.2.9.13.2SECTION 431.615
   431.615 Relations with State health and vocational rehabilitation agencies and title V grantees.
42:4.0.1.1.2.9.13.3SECTION 431.620
   431.620 Agreement with State mental health authority or mental institutions.
42:4.0.1.1.2.9.13.4SECTION 431.621
   431.621 State requirements with respect to nursing facilities.
42:4.0.1.1.2.9.13.5SECTION 431.625
   431.625 Coordination of Medicaid with Medicare part B.
42:4.0.1.1.2.9.13.6SECTION 431.630
   431.630 Coordination of Medicaid with QIOs.
42:4.0.1.1.2.9.13.7SECTION 431.635
   431.635 Coordination of Medicaid with Special Supplemental Food Program for Women, Infants, and Children (WIC).
42:4.0.1.1.2.10SUBPART N
Subpart N - State Programs for Licensing Nursing Home Administrators
42:4.0.1.1.2.10.13.1SECTION 431.700
   431.700 Basis and purpose.
42:4.0.1.1.2.10.13.2SECTION 431.701
   431.701 Definitions.
42:4.0.1.1.2.10.13.3SECTION 431.702
   431.702 State plan requirement.
42:4.0.1.1.2.10.13.4SECTION 431.703
   431.703 Licensing requirement.
42:4.0.1.1.2.10.13.5SECTION 431.704
   431.704 Nursing homes designated by other terms.
42:4.0.1.1.2.10.13.6SECTION 431.705
   431.705 Licensing authority.
42:4.0.1.1.2.10.13.7SECTION 431.706
   431.706 Composition of licensing board.
42:4.0.1.1.2.10.13.8SECTION 431.707
   431.707 Standards.
42:4.0.1.1.2.10.13.9SECTION 431.708
   431.708 Procedures for applying standards.
42:4.0.1.1.2.10.13.10SECTION 431.709
   431.709 Issuance and revocation of license.
42:4.0.1.1.2.10.13.11SECTION 431.710
   431.710 Provisional licenses.
42:4.0.1.1.2.10.13.12SECTION 431.711
   431.711 Compliance with standards.
42:4.0.1.1.2.10.13.13SECTION 431.712
   431.712 Failure to comply with standards.
42:4.0.1.1.2.10.13.14SECTION 431.713
   431.713 Continuing study and investigation.
42:4.0.1.1.2.10.13.15SECTION 431.714
   431.714 Waivers.
42:4.0.1.1.2.10.13.16SECTION 431.715
   431.715 Federal financial participation.
42:4.0.1.1.2.11SUBPART O
Subpart O [Reserved]
42:4.0.1.1.2.12SUBPART P
Subpart P - Quality Control
42:4.0.1.1.2.12.13SUBJGRP 13
   Medicaid Eligibility Quality Control (MEQC) Program
42:4.0.1.1.2.12.13.1SECTION 431.800
   431.800 Basis and scope.
42:4.0.1.1.2.12.13.2SECTION 431.804
   431.804 Definitions.
42:4.0.1.1.2.12.13.3SECTION 431.806
   431.806 State requirements.
42:4.0.1.1.2.12.13.4SECTION 431.808
   431.808 Protection of beneficiary rights.
42:4.0.1.1.2.12.13.5SECTION 431.810
   431.810 Basic elements of the Medicaid Eligibility Quality Control (MEQC) Program.
42:4.0.1.1.2.12.13.6SECTION 431.812
   431.812 Review procedures.
42:4.0.1.1.2.12.13.7SECTION 431.814
   431.814 Pilot planning document.
42:4.0.1.1.2.12.13.8SECTION 431.816
   431.816 Case review completion deadlines and submittal of reports.
42:4.0.1.1.2.12.13.9SECTION 431.818
   431.818 Access to records.
42:4.0.1.1.2.12.13.10SECTION 431.820
   431.820 Corrective action under the MEQC program.
42:4.0.1.1.2.12.14SUBJGRP 14
   Medicaid Quality Control (MQC) Claims Processing Assessment System
42:4.0.1.1.2.12.14.11SECTION 431.830
   431.830 Basic elements of the Medicaid quality control (MQC) claims processing assessment system.
42:4.0.1.1.2.12.14.12SECTION 431.832
   431.832 Reporting requirements for claims processing assessment systems.
42:4.0.1.1.2.12.14.13SECTION 431.834
   431.834 Access to records: Claims processing assessment systems.
42:4.0.1.1.2.12.14.14SECTION 431.836
   431.836 Corrective action under the MQC claims processing assessment system.
42:4.0.1.1.2.13SUBPART Q
Subpart Q - Requirements for Estimating Improper Payments in Medicaid and CHIP
42:4.0.1.1.2.13.15.1SECTION 431.950
   431.950 Purpose.
42:4.0.1.1.2.13.15.2SECTION 431.954
   431.954 Basis and scope.
42:4.0.1.1.2.13.15.3SECTION 431.958
   431.958 Definitions and use of terms.
42:4.0.1.1.2.13.15.4SECTION 431.960
   431.960 Types of payment errors.
42:4.0.1.1.2.13.15.5SECTION 431.970
   431.970 Information submission and systems access requirements.
42:4.0.1.1.2.13.15.6SECTION 431.972
   431.972 Claims sampling procedures.
42:4.0.1.1.2.13.15.7SECTION 431.992
   431.992 Corrective action plan.
42:4.0.1.1.2.13.15.8SECTION 431.998
   431.998 Difference resolution and appeal process.
42:4.0.1.1.2.13.15.9SECTION 431.1002
   431.1002 Recoveries.
42:4.0.1.1.2.13.15.10SECTION 431.1010
   431.1010 Disallowance of Federal financial participation for erroneous State payments (for PERM review years ending after July 1, 2020).