Title 42, Part 438 — Managed Care

Basis and scope.

Definitions.

Standard contract requirements.

Actuarial soundness.

Rate development standards.

Special contract provisions related to payment.

Rate certification submission.

Medical loss ratio (MLR) standards.

Provisions that apply to non-emergency medical transportation PAHPs.

Information requirements.

Provider discrimination prohibited.

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).

In lieu of services and settings (ILOS) requirements.

State Plan requirements.

Choice of MCOs, PIHPs, PAHPs, PCCMs, and PCCM entities.

Managed care enrollment.

Disenrollment: Requirements and limitations.

Conflict of interest safeguards.

Prohibition of additional payments for services covered under MCO, PIHP or PAHP contracts.

Continued services to enrollees.

State monitoring requirements.

Network adequacy standards.

Stakeholder engagement when LTSS is delivered through a managed care program.

Beneficiary support system.

Additional requirements for long-term services and supports.

State oversight of the minimum MLR requirement.

Enrollee rights.

Provider-enrollee communications.

Marketing activities.

Liability for payment.

Cost sharing.

Member advisory committee.

Emergency and poststabilization services.

Solvency standards.

Availability of services.

Assurances of adequate capacity and services.

Coordination and continuity of care.

Coverage and authorization of services.

Provider selection.

Confidentiality.

Grievance and appeal systems.

Subcontractual relationships and delegation.

Practice guidelines.

Health information systems.

Basis, scope, and applicability.

Definitions.

Quality assessment and performance improvement program.

State review of the accreditation status of MCOs, PIHPs, and PAHPs.

[Reserved]

Managed care State quality strategy.

External quality review.

External quality review protocols.

Qualifications of external quality review organizations.

State contract options for external quality review.

Activities related to external quality review.

Nonduplication of mandatory activities with Medicare or accreditation review.

Exemption from external quality review.

External quality review results.

Federal financial participation (FFP).

Statutory basis, definitions, and applicability.

General requirements.

Timely and adequate notice of adverse benefit determination.

Handling of grievances and appeals.

Resolution and notification: Grievances and appeals.

Expedited resolution of appeals.

Information about the grievance and appeal system to providers and subcontractors.

Recordkeeping requirements.

Continuation of benefits while the MCO, PIHP, or PAHP appeal and the State fair hearing are pending.

Effectuation of reversed appeal resolutions.

Definitions.

General rule and applicability.

Mandatory QRS measure set for Medicaid managed care quality rating system.

Medicaid managed care quality rating system methodology.

website display.

[Reserved]

Annual technical resource manual.

Annual reporting.

Statutory basis, basic rule, and applicability.

State responsibilities.

Data, information, and documentation that must be submitted.

Source, content, and timing of certification.

Program integrity requirements under the contract.

Prohibited affiliations.

Basis for imposition of sanctions.

Types of intermediate sanctions.

Amounts of civil money penalties.

Special rules for temporary management.

Termination of an MCO, PCCM or PCCM entity contract.

Notice of sanction and pre-termination hearing.

Disenrollment during termination hearing process.

Notice to CMS.

State plan requirement.

Sanction by CMS: Special rules for MCOs.

Basic requirements.

Prior approval.

Exclusion of entities.

Expenditures for enrollment broker services.

Costs under risk and nonrisk contracts.

Expenditures for the beneficiary support system for enrollees using LTSS.

Enrollee encounter data.

Meaning of terms.

Parity requirements for aggregate lifetime and annual dollar limits.

Parity requirements for financial requirements and treatment limitations.

Availability of information.

Applicability.

Compliance dates.