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FEDERAL · 42 CFR

Part 438 — Managed Care

106 sections · Title 42: Public Health

§ 438.1Basis and scope.
§ 438.2Definitions.
§ 438.3Standard contract requirements.
§ 438.4Actuarial soundness.
§ 438.5Rate development standards.
§ 438.6Special contract provisions related to payment.
§ 438.7Rate certification submission.
§ 438.8Medical loss ratio (MLR) standards.
§ 438.9Provisions that apply to non-emergency medical transportation PAHPs.
§ 438.10Information requirements.
§ 438.12Provider discrimination prohibited.
§ 438.14Requirements that apply to MCO, PIHP, PAHP, PCCM, and PCCM entity contracts involving Indians, Indian health care providers (IHCPs), and Indian managed care entities (IMCEs).
§ 438.16In lieu of services and settings (ILOS) requirements.
§ 438.50State Plan requirements.
§ 438.52Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities.
§ 438.54Managed care enrollment.
§ 438.56Disenrollment: Requirements and limitations.
§ 438.58Conflict of interest safeguards.
§ 438.60Prohibition of additional payments for services covered under MCO, PIHP or PAHP contracts.
§ 438.62Continued services to enrollees.
§ 438.66State monitoring requirements.
§ 438.68Network adequacy standards.
§ 438.70Stakeholder engagement when LTSS is delivered through a managed care program.
§ 438.71Beneficiary support system.
§ 438.72Additional requirements for long-term services and supports.
§ 438.74State oversight of the minimum MLR requirement.
§ 438.100Enrollee rights.
§ 438.102Provider-enrollee communications.
§ 438.104Marketing activities.
§ 438.106Liability for payment.
§ 438.108Cost sharing.
§ 438.110Member advisory committee.
§ 438.114Emergency and poststabilization services.
§ 438.116Solvency standards.
§ 438.206Availability of services.
§ 438.207Assurances of adequate capacity and services.
§ 438.208Coordination and continuity of care.
§ 438.210Coverage and authorization of services.
§ 438.214Provider selection.
§ 438.224Confidentiality.
§ 438.228Grievance and appeal systems.
§ 438.230Subcontractual relationships and delegation.
§ 438.236Practice guidelines.
§ 438.242Health information systems.
§ 438.310Basis, scope, and applicability.
§ 438.320Definitions.
§ 438.330Quality assessment and performance improvement program.
§ 438.332State review of the accreditation status of MCOs, PIHPs, and PAHPs.
§ 438.334§ 438.334 [Reserved]
§ 438.340Managed care State quality strategy.
§ 438.350External quality review.
§ 438.352External quality review protocols.
§ 438.354Qualifications of external quality review organizations.
§ 438.356State contract options for external quality review.
§ 438.358Activities related to external quality review.
§ 438.360Nonduplication of mandatory activities with Medicare or accreditation review.
§ 438.362Exemption from external quality review.
§ 438.364External quality review results.
§ 438.370Federal financial participation (FFP).
§ 438.400Statutory basis, definitions, and applicability.
§ 438.402General requirements.
§ 438.404Timely and adequate notice of adverse benefit determination.
§ 438.406Handling of grievances and appeals.
§ 438.408Resolution and notification: Grievances and appeals.
§ 438.410Expedited resolution of appeals.
§ 438.414Information about the grievance and appeal system to providers and subcontractors.
§ 438.416Recordkeeping requirements.
§ 438.420Continuation of benefits while the MCO, PIHP, or PAHP appeal and the State fair hearing are pending.
§ 438.424Effectuation of reversed appeal resolutions.
§ 438.500Definitions.
§ 438.505General rule and applicability.
§ 438.510Mandatory QRS measure set for Medicaid managed care quality rating system.
§ 438.515Medicaid managed care quality rating system methodology.
§ 438.520website display.
§ 438.525§ 438.525 [Reserved]
§ 438.530Annual technical resource manual.
§ 438.535Annual reporting.
§ 438.600Statutory basis, basic rule, and applicability.
§ 438.602State responsibilities.
§ 438.604Data, information, and documentation that must be submitted.
§ 438.606Source, content, and timing of certification.
§ 438.608Program integrity requirements under the contract.
§ 438.610Prohibited affiliations.
§ 438.700Basis for imposition of sanctions.
§ 438.702Types of intermediate sanctions.
§ 438.704Amounts of civil money penalties.
§ 438.706Special rules for temporary management.
§ 438.708Termination of an MCO, PCCM or PCCM entity contract.
§ 438.710Notice of sanction and pre-termination hearing.
§ 438.722Disenrollment during termination hearing process.
§ 438.724Notice to CMS.
§ 438.726State plan requirement.
§ 438.730Sanction by CMS: Special rules for MCOs.
§ 438.802Basic requirements.
§ 438.806Prior approval.
§ 438.808Exclusion of entities.
§ 438.810Expenditures for enrollment broker services.
§ 438.812Costs under risk and nonrisk contracts.
§ 438.816Expenditures for the beneficiary support system for enrollees using LTSS.
§ 438.818Enrollee encounter data.
§ 438.900Meaning of terms.
§ 438.905Parity requirements for aggregate lifetime and annual dollar limits.
§ 438.910Parity requirements for financial requirements and treatment limitations.
§ 438.915Availability of information.
§ 438.920Applicability.
§ 438.930Compliance dates.