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Code of Federal Regulations (Last Updated: November 8, 2024) |
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Title 42 - Public Health |
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Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services |
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SubChapter C - Medical Assistance Programs |
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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 |
| § 438.100 - Enrollee rights. |
| § 438.102 - Provider-enrollee communications. |
| § 438.104 - Marketing activities. |
| § 438.106 - Liability for payment. |
| § 438.108 - Cost sharing. |
| § 438.110 - Member advisory committee. |
| § 438.114 - Emergency and poststabilization services. |
| § 438.116 - Solvency standards. |
| Subpart D - MCO, PIHP and PAHP Standards |
| § 438.200 - Scope. |
| § 438.202 - State responsibilities. |
| § 438.204 - Elements of State quality strategies. |
| § 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. |
| Access Standards |
| Measurement and Improvement Standards |
| § 438.240 - Quality assessment and performance improvement program. |
| Structure and Operation Standards |
| § 438.218 - Enrollee information. |
| § 438.226 - Enrollment and disenrollment. |
| 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. |
| § 438.334 - [Reserved] |
| § 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. |
| § 438.426 - Monitoring of the grievance system. |
| 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. |
| § 438.525 - [Reserved] |
| § 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. |
| § 438.804 - Primary care provider payment increases. |
| § 438.806 - Prior approval. |
| § 438.808 - Exclusion of entities. |
| § 438.810 - Expenditures for enrollment broker services. |
| § 438.812 - Costs under risk and nonrisk contracts. |
| § 438.814 - Limit on payments in excess of capitation rates. |
| § 438.816 - Expenditures for the beneficiary support system for enrollees using LTSS. |
| § 438.818 - Enrollee encounter data. |
| Subpart K - Parity in Mental Health and Substance Use Disorder Benefits |
| § 438.900 - Meaning of terms. |
| § 438.905 - Parity requirements for aggregate lifetime and annual dollar limits. |
| § 438.910 - Parity requirements for financial requirements and treatment limitations. |
| § 438.915 - Availability of information. |
| § 438.920 - Applicability. |
| § 438.930 - Compliance dates. |