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Title 42, Part 417 — Health Maintenance Organizations, Competitive Medical Plans, and Health Care Prepayment Plans

148 sections

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