Home/CFR/Title 42/Part 417
FEDERAL · 42 CFR

Part 417 — Health Maintenance Organizations, Competitive Medical Plans, and Health Care Prepayment Plans

148 sections · Title 42: Public Health

§ 417.1Definitions.
§ 417.2Basis and scope.
§ 417.101Health benefits plan: Basic health services.
§ 417.102Health benefits plan: Supplemental health services.
§ 417.103Providers of basic and supplemental health services.
§ 417.104Payment for basic health services.
§ 417.105Payment for supplemental health services.
§ 417.106Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services.
§ 417.120Fiscally sound operation and assumption of financial risk.
§ 417.122Protection of enrollees.
§ 417.124Administration and management.
§ 417.126Recordkeeping and reporting requirements.
§ 417.140Scope.
§ 417.142Requirements for qualification.
§ 417.143Application requirements.
§ 417.144Evaluation and determination procedures.
§ 417.150Definitions.
§ 417.151Applicability.
§ 417.153Offer of HMO alternative.
§ 417.155How the HMO option must be included in the health benefits plan.
§ 417.156When the HMO must be offered to employees.
§ 417.157Contributions for the HMO alternative.
§ 417.158Payroll deductions.
§ 417.159Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway Labor Act.
§ 417.160Applicability.
§ 417.161Compliance with assurances.
§ 417.162Reporting requirements.
§ 417.163Enforcement procedures.
§ 417.164Effect of revocation of qualification on inclusion in employee's health benefit plans.
§ 417.165Reapplication for qualification.
§ 417.166Waiver of assurances.
§ 417.400Basis and scope.
§ 417.401Definitions.
§ 417.402Effective date of initial regulations.
§ 417.404General requirements.
§ 417.406Application and determination.
§ 417.407Requirements for a Competitive Medical Plan (CMP).
§ 417.408Contract application process.
§ 417.410Qualifying conditions: General rules.
§ 417.412Qualifying condition: Administration and management.
§ 417.413Qualifying condition: Operating experience and enrollment.
§ 417.414Qualifying condition: Range of services.
§ 417.416Qualifying condition: Furnishing of services.
§ 417.418Qualifying condition: Quality assurance program.
§ 417.420Basic rules on enrollment and entitlement.
§ 417.422Eligibility to enroll in an HMO or CMP.
§ 417.423Special rules: ESRD and hospice patients.
§ 417.424Denial of enrollment.
§ 417.426Open enrollment requirements.
§ 417.427Extending MA and Part D program disclosure requirements to section 1876 cost contract plans.
§ 417.428Marketing activities.
§ 417.430Application procedures.
§ 417.432Conversion of enrollment.
§ 417.434Reenrollment.
§ 417.436Rules for enrollees.
§ 417.440Entitlement to health care services from an HMO or CMP.
§ 417.442Risk HMO's and CMP's: Conditions for provision of additional benefits.
§ 417.444Special rules for certain enrollees of risk HMOs and CMPs.
§ 417.446§ 417.446 [Reserved]
§ 417.448Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.
§ 417.450Effective date of coverage.
§ 417.452Liability of Medicare enrollees.
§ 417.454Charges to Medicare enrollees.
§ 417.456Refunds to Medicare enrollees.
§ 417.458Recoupment of uncollected deductible and coinsurance amounts.
§ 417.460Disenrollment of beneficiaries by an HMO or CMP.
§ 417.461Disenrollment by the enrollee.
§ 417.464End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract.
§ 417.470Basis and scope.
§ 417.472Basic contract requirements.
§ 417.474Effective date and term of contract.
§ 417.476Waived conditions.
§ 417.478Requirements of other laws and regulations.
§ 417.479Requirements for physician incentive plans.
§ 417.480Maintenance of records: Cost HMOs and CMPs.
§ 417.481Maintenance of records: Risk HMOs and CMPs.
§ 417.482Access to facilities and records.
§ 417.484Requirement applicable to related entities.
§ 417.486Disclosure of information and confidentiality.
§ 417.488Notice of termination and of available alternatives: Risk contract.
§ 417.490Renewal of contract.
§ 417.492Nonrenewal of contract.
§ 417.494Modification or termination of contract.
§ 417.496Cost plan crosswalk.
§ 417.500Intermediate sanctions for and civil monetary penalties against HMOs and CMPs.
§ 417.520Effect on HMO and CMP contracts.
§ 417.524Payment to HMOs or CMPs: General.
§ 417.526Payment for covered services.
§ 417.528Payment when Medicare is not primary payer.
§ 417.530Basis and scope.
§ 417.531Hospice care services.
§ 417.532General considerations.
§ 417.533Part B carrier responsibilities.
§ 417.534Allowable costs.
§ 417.536Cost payment principles.
§ 417.538Enrollment and marketing costs.
§ 417.540Enrollment costs.
§ 417.542Reinsurance costs.
§ 417.544Physicians' services furnished directly by the HMO or CMP.
§ 417.546Physicians' services and other Part B supplier services furnished under arrangements.
§ 417.548Provider services through arrangements.
§ 417.550Special Medicare program requirements.
§ 417.552Cost apportionment: General provisions.
§ 417.554Apportionment: Provider services furnished directly by the HMO or CMP.
§ 417.556Apportionment: Provider services furnished by the HMO or CMP through arrangements with others.
§ 417.558Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility.
§ 417.560Apportionment: Part B physician and supplier services.
§ 417.564Apportionment and allocation of administrative and general costs.
§ 417.566Other methods of allocation and apportionment.
§ 417.568Adequate financial records, statistical data, and cost finding.
§ 417.570Interim per capita payments.
§ 417.572Budget and enrollment forecast and interim reports.
§ 417.574Interim settlement.
§ 417.576Final settlement.
§ 417.580Basis and scope.
§ 417.582Definitions.
§ 417.584Payment to HMOs or CMPs with risk contracts.
§ 417.585Special rules: Hospice care.
§ 417.588Computation of adjusted average per capita cost (AAPCC).
§ 417.590Computation of the average of the per capita rates of payment.
§ 417.592Additional benefits requirement.
§ 417.594Computation of adjusted community rate (ACR).
§ 417.596Establishment of a benefit stabilization fund.
§ 417.597Withdrawal from a benefit stabilization fund.
§ 417.598Annual enrollment reconciliation.
§ 417.600Basis and scope.
§ 417.640Applicability.
§ 417.800Payment to HCPPs: Definitions and basic rules.
§ 417.801Agreements between CMS and health care prepayment plans.
§ 417.802Allowable costs.
§ 417.804Cost apportionment.
§ 417.806Financial records, statistical data, and cost finding.
§ 417.808Interim per capita payments.
§ 417.810Final settlement.
§ 417.830Scope of regulations on beneficiary appeals.
§ 417.832Applicability of requirements and procedures.
§ 417.834Responsibility for establishing administrative review procedures.
§ 417.836Written description of administrative review procedures.
§ 417.838Organization determinations.
§ 417.840Administrative review procedures.
§ 417.910Applicability.
§ 417.911Definitions.
§ 417.920Planning and initial development.
§ 417.930Initial costs of operation.
§ 417.931§ 417.931 [Reserved]
§ 417.934Reserve requirement.
§ 417.937Loan and loan guarantee provisions.
§ 417.940Civil action to enforce compliance with assurances.