Part 438 — Managed Care
Subpart A — General Provisions
- § 438.1— Basis and scope.
- § 438.2— Definitions.
- § 438.3— Standard contract requirements.
- § 438.4— Actuarial soundness.
- § 438.5— Rate development standards.
- § 438.6— Special contract provisions related to payment.
- § 438.7— Rate certification submission.
- § 438.8— Medical loss ratio (MLR) standards.
- § 438.9— Provisions that apply to non-emergency medical transportation PAHPs.
- § 438.10— Information requirements.
- § 438.12— Provider discrimination prohibited.
- § 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).
- § 438.16— In lieu of services and settings (ILOS) requirements.
Subpart B — State Responsibilities
- § 438.50— State Plan requirements.
- § 438.52— Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities.
- § 438.54— Managed care enrollment.
- § 438.56— Disenrollment: Requirements and limitations.
- § 438.58— Conflict of interest safeguards.
- § 438.60— Prohibition of additional payments for services covered under MCO, PIHP or PAHP contracts.
- § 438.62— Continued services to enrollees.
- § 438.66— State monitoring requirements.
- § 438.68— Network adequacy standards.
- § 438.70— Stakeholder engagement when LTSS is delivered through a managed care program.
- § 438.71— Beneficiary support system.
- § 438.72— Additional requirements for long-term services and supports.
- § 438.74— State oversight of the minimum MLR requirement.
Subpart C — Enrollee Rights and Protections
Subpart D — MCO, PIHP and PAHP Standards
- § 438.206— Availability of services.
- § 438.207— Assurances of adequate capacity and services.
- § 438.208— Coordination and continuity of care.
- § 438.210— Coverage and authorization of services.
- § 438.214— Provider selection.
- § 438.224— Confidentiality.
- § 438.228— Grievance and appeal systems.
- § 438.230— Subcontractual relationships and delegation.
- § 438.236— Practice guidelines.
- § 438.242— Health information systems.
Subpart E — Quality Measurement and Improvement; External Quality Review
- § 438.310— Basis, scope, and applicability.
- § 438.320— Definitions.
- § 438.330— Quality assessment and performance improvement program.
- § 438.332— State review of the accreditation status of MCOs, PIHPs, and PAHPs.
- § 438.340— Managed care State quality strategy.
- § 438.350— External quality review.
- § 438.352— External quality review protocols.
- § 438.354— Qualifications of external quality review organizations.
- § 438.356— State contract options for external quality review.
- § 438.358— Activities related to external quality review.
- § 438.360— Nonduplication of mandatory activities with Medicare or accreditation review.
- § 438.362— Exemption from external quality review.
- § 438.364— External quality review results.
- § 438.370— Federal financial participation (FFP).
Subpart F — Grievance and Appeal System
- § 438.400— Statutory basis, definitions, and applicability.
- § 438.402— General requirements.
- § 438.404— Timely and adequate notice of adverse benefit determination.
- § 438.406— Handling of grievances and appeals.
- § 438.408— Resolution and notification: Grievances and appeals.
- § 438.410— Expedited resolution of appeals.
- § 438.414— Information about the grievance and appeal system to providers and subcontractors.
- § 438.416— Recordkeeping requirements.
- § 438.420— Continuation of benefits while the MCO, PIHP, or PAHP appeal and the State fair hearing are pending.
- § 438.424— Effectuation of reversed appeal resolutions.
Subpart G — Medicaid Managed Care Quality Rating System
- § 438.500— Definitions.
- § 438.505— General rule and applicability.
- § 438.510— Mandatory QRS measure set for Medicaid managed care quality rating system.
- § 438.515— Medicaid managed care quality rating system methodology.
- § 438.520— website display.
- § 438.530— Annual technical resource manual.
- § 438.535— Annual reporting.
Subpart H — Additional Program Integrity Safeguards
- § 438.600— Statutory basis, basic rule, and applicability.
- § 438.602— State responsibilities.
- § 438.604— Data, information, and documentation that must be submitted.
- § 438.606— Source, content, and timing of certification.
- § 438.608— Program integrity requirements under the contract.
- § 438.610— Prohibited affiliations.
Subpart I — Sanctions
- § 438.700— Basis for imposition of sanctions.
- § 438.702— Types of intermediate sanctions.
- § 438.704— Amounts of civil money penalties.
- § 438.706— Special rules for temporary management.
- § 438.708— Termination of an MCO, PCCM or PCCM entity contract.
- § 438.710— Notice of sanction and pre-termination hearing.
- § 438.722— Disenrollment during termination hearing process.
- § 438.724— Notice to CMS.
- § 438.726— State plan requirement.
- § 438.730— Sanction by CMS: Special rules for MCOs.
Subpart J — Conditions for Federal Financial Participation (FFP)
- § 438.802— Basic requirements.
- § 438.806— Prior approval.
- § 438.808— Exclusion of entities.
- § 438.810— Expenditures for enrollment broker services.
- § 438.812— Costs under risk and nonrisk contracts.
- § 438.816— Expenditures for the beneficiary support system for enrollees using LTSS.
- § 438.818— Enrollee encounter data.