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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 B - Medicare Program |
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Part 417 - Health Maintenance Organizations, Competitive Medical Plans, and Health Care Prepayment Plans |
Part 417 - Health Maintenance Organizations, Competitive Medical Plans, and Health Care Prepayment Plans
| Subpart A - General Provisions |
| § 417.1 - Definitions. |
| § 417.2 - Basis and scope. |
| Subpart B - Qualified Health Maintenance Organizations: Services |
| § 417.101 - Health benefits plan: Basic health services. |
| § 417.102 - Health benefits plan: Supplemental health services. |
| § 417.103 - Providers of basic and supplemental health services. |
| § 417.104 - Payment for basic health services. |
| § 417.105 - Payment for supplemental health services. |
| § 417.106 - Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services. |
| Subpart C - Qualified Health Maintenance Organizations: Organization and Operation |
| § 417.120 - Fiscally sound operation and assumption of financial risk. |
| § 417.122 - Protection of enrollees. |
| § 417.124 - Administration and management. |
| § 417.126 - Recordkeeping and reporting requirements. |
| Subpart D - Application for Federal Qualification |
| § 417.140 - Scope. |
| § 417.142 - Requirements for qualification. |
| § 417.143 - Application requirements. |
| § 417.144 - Evaluation and determination procedures. |
| Subpart E - Inclusion of Qualified Health Maintenance Organizations in Employee Health Benefits Plans |
| § 417.150 - Definitions. |
| § 417.151 - Applicability. |
| § 417.153 - Offer of HMO alternative. |
| § 417.155 - How the HMO option must be included in the health benefits plan. |
| § 417.156 - When the HMO must be offered to employees. |
| § 417.157 - Contributions for the HMO alternative. |
| § 417.158 - Payroll deductions. |
| § 417.159 - Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway Labor Act. |
| Subpart F - Continued Regulation of Federally Qualified Health Maintenance Organizations |
| § 417.160 - Applicability. |
| § 417.161 - Compliance with assurances. |
| § 417.162 - Reporting requirements. |
| § 417.163 - Enforcement procedures. |
| § 417.164 - Effect of revocation of qualification on inclusion in employee's health benefit plans. |
| § 417.165 - Reapplication for qualification. |
| § 417.166 - Waiver of assurances. |
| Subparts G--I - XXX |
| Subpart J - Qualifying Conditions for Medicare Contracts |
| § 417.400 - Basis and scope. |
| § 417.401 - Definitions. |
| § 417.402 - Effective date of initial regulations. |
| § 417.404 - General requirements. |
| § 417.406 - Application and determination. |
| § 417.407 - Requirements for a Competitive Medical Plan (CMP). |
| § 417.408 - Contract application process. |
| § 417.410 - Qualifying conditions: General rules. |
| § 417.412 - Qualifying condition: Administration and management. |
| § 417.413 - Qualifying condition: Operating experience and enrollment. |
| § 417.414 - Qualifying condition: Range of services. |
| § 417.416 - Qualifying condition: Furnishing of services. |
| § 417.418 - Qualifying condition: Quality assurance program. |
| Subpart K - Enrollment, Entitlement, and Disenrollment under Medicare Contract |
| § 417.420 - Basic rules on enrollment and entitlement. |
| § 417.422 - Eligibility to enroll in an HMO or CMP. |
| § 417.423 - Special rules: ESRD and hospice patients. |
| § 417.424 - Denial of enrollment. |
| § 417.426 - Open enrollment requirements. |
| § 417.427 - Extending MA and Part D program disclosure requirements to section 1876 cost contract plans. |
| § 417.428 - Marketing activities. |
| § 417.430 - Application procedures. |
| § 417.432 - Conversion of enrollment. |
| § 417.434 - Reenrollment. |
| § 417.436 - Rules for enrollees. |
| § 417.440 - Entitlement to health care services from an HMO or CMP. |
| § 417.442 - Risk HMO's and CMP's: Conditions for provision of additional benefits. |
| § 417.444 - Special rules for certain enrollees of risk HMOs and CMPs. |
| § 417.446 - [Reserved] |
| § 417.448 - Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs. |
| § 417.450 - Effective date of coverage. |
| § 417.452 - Liability of Medicare enrollees. |
| § 417.454 - Charges to Medicare enrollees. |
| § 417.456 - Refunds to Medicare enrollees. |
| § 417.458 - Recoupment of uncollected deductible and coinsurance amounts. |
| § 417.460 - Disenrollment of beneficiaries by an HMO or CMP. |
| § 417.461 - Disenrollment by the enrollee. |
| § 417.464 - End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract. |
| Subpart L - Medicare Contract Requirements |
| § 417.470 - Basis and scope. |
| § 417.472 - Basic contract requirements. |
| § 417.474 - Effective date and term of contract. |
| § 417.476 - Waived conditions. |
| § 417.478 - Requirements of other laws and regulations. |
| § 417.479 - Requirements for physician incentive plans. |
| § 417.480 - Maintenance of records: Cost HMOs and CMPs. |
| § 417.481 - Maintenance of records: Risk HMOs and CMPs. |
| § 417.482 - Access to facilities and records. |
| § 417.484 - Requirement applicable to related entities. |
| § 417.486 - Disclosure of information and confidentiality. |
| § 417.488 - Notice of termination and of available alternatives: Risk contract. |
| § 417.490 - Renewal of contract. |
| § 417.492 - Nonrenewal of contract. |
| § 417.494 - Modification or termination of contract. |
| § 417.496 - xxx |
| § 417.500 - Intermediate sanctions for and civil monetary penalties against HMOs and CMPs. |
| Subpart M - Change of Ownership and Leasing of Facilities: Effect on Medicare Contract |
| § 417.520 - Effect on HMO and CMP contracts. |
| Subpart N - Medicare Payment to HMOs and CMPs: General Rules |
| § 417.524 - Payment to HMOs or CMPs: General. |
| § 417.526 - Payment for covered services. |
| § 417.528 - Payment when Medicare is not primary payer. |
| Subpart O - Medicare Payment: Cost Basis |
| § 417.530 - Basis and scope. |
| § 417.531 - Hospice care services. |
| § 417.532 - General considerations. |
| § 417.533 - Part B carrier responsibilities. |
| § 417.534 - Allowable costs. |
| § 417.536 - Cost payment principles. |
| § 417.538 - Enrollment and marketing costs. |
| § 417.540 - Enrollment costs. |
| § 417.542 - Reinsurance costs. |
| § 417.544 - Physicians' services furnished directly by the HMO or CMP. |
| § 417.546 - Physicians' services and other Part B supplier services furnished under arrangements. |
| § 417.548 - Provider services through arrangements. |
| § 417.550 - Special Medicare program requirements. |
| § 417.552 - Cost apportionment: General provisions. |
| § 417.554 - Apportionment: Provider services furnished directly by the HMO or CMP. |
| § 417.556 - Apportionment: Provider services furnished by the HMO or CMP through arrangements with others. |
| § 417.558 - Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility. |
| § 417.560 - Apportionment: Part B physician and supplier services. |
| § 417.564 - Apportionment and allocation of administrative and general costs. |
| § 417.566 - Other methods of allocation and apportionment. |
| § 417.568 - Adequate financial records, statistical data, and cost finding. |
| § 417.570 - Interim per capita payments. |
| § 417.572 - Budget and enrollment forecast and interim reports. |
| § 417.574 - Interim settlement. |
| § 417.576 - Final settlement. |
| Subpart P - Medicare Payment: Risk Basis |
| § 417.580 - Basis and scope. |
| § 417.582 - Definitions. |
| § 417.584 - Payment to HMOs or CMPs with risk contracts. |
| § 417.585 - Special rules: Hospice care. |
| § 417.588 - Computation of adjusted average per capita cost (AAPCC). |
| § 417.590 - Computation of the average of the per capita rates of payment. |
| § 417.592 - Additional benefits requirement. |
| § 417.594 - Computation of adjusted community rate (ACR). |
| § 417.596 - Establishment of a benefit stabilization fund. |
| § 417.597 - Withdrawal from a benefit stabilization fund. |
| § 417.598 - Annual enrollment reconciliation. |
| Subpart Q - Beneficiary Appeals |
| § 417.600 - Basis and scope. |
| § 417.602 - Definitions. |
| § 417.604 - General provisions. |
| § 417.605 - Immediate QIO review of a determination of noncoverage of inpatient hospital care. |
| § 417.606 - Organization determinations. |
| § 417.608 - Notice of adverse organization determination. |
| § 417.609 - Expediting certain organization determinations. |
| § 417.610 - Parties to the organization determination. |
| § 417.612 - Effect of organization determination. |
| § 417.614 - Right to reconsideration. |
| § 417.616 - Request for reconsideration. |
| § 417.617 - Expediting certain reconsiderations. |
| § 417.618 - Opportunity to submit evidence. |
| § 417.620 - Responsibility for reconsiderations; time limits. |
| § 417.622 - Reconsidered determination. |
| § 417.624 - Notice of reconsidered determination. |
| § 417.626 - Effect of reconsidered determination. |
| § 417.630 - Right to a hearing. |
| § 417.632 - Request for hearing. |
| § 417.634 - Departmental Appeals Board (DAB) review. |
| § 417.636 - Court review. |
| § 417.638 - Reopening determinations and decisions. |
| Subpart R - Medicare Contract Appeals |
| § 417.640 - Applicability. |
| § 417.642 - Administrative actions that are not initial determinations. |
| § 417.644 - Notice of initial determination. |
| § 417.646 - Effect of initial determination. |
| § 417.648 - Reconsideration: Applicability. |
| § 417.650 - Request for reconsideration. |
| § 417.652 - Opportunity to submit evidence. |
| § 417.654 - Reconsidered determination. |
| § 417.656 - Notice of reconsidered determination. |
| § 417.658 - Effect of reconsidered determination. |
| § 417.660 - Right to a hearing. |
| § 417.662 - Request for hearing. |
| § 417.664 - Postponement of effective date of initial determination. |
| § 417.666 - Designation of hearing officer. |
| § 417.668 - Disqualification of hearing officer. |
| § 417.670 - Time and place of hearing. |
| § 417.672 - Appointment of representatives. |
| § 417.674 - Authority of representatives. |
| § 417.676 - Conduct of hearing. |
| § 417.678 - Evidence. |
| § 417.680 - Witnesses. |
| § 417.682 - Discovery. |
| § 417.684 - Prehearing. |
| § 417.686 - Record of hearing. |
| § 417.688 - Authority of hearing officer. |
| § 417.690 - Notice and effect of hearing decision. |
| § 417.692 - Reopening of initial or reconsidered determination or decision of a hearing officer. |
| § 417.694 - Effect of revised determination. |
| Subparts S--T - XXX |
| Subpart U - Health Care Prepayment Plans |
| § 417.800 - Payment to HCPPs: Definitions and basic rules. |
| § 417.801 - Agreements between CMS and health care prepayment plans. |
| § 417.802 - Allowable costs. |
| § 417.804 - Cost apportionment. |
| § 417.806 - Financial records, statistical data, and cost finding. |
| § 417.808 - Interim per capita payments. |
| § 417.810 - Final settlement. |
| § 417.830 - Scope of regulations on beneficiary appeals. |
| § 417.832 - Applicability of requirements and procedures. |
| § 417.834 - Responsibility for establishing administrative review procedures. |
| § 417.836 - Written description of administrative review procedures. |
| § 417.838 - Organization determinations. |
| § 417.840 - Administrative review procedures. |
| Subpart V - Administration of Outstanding Loans and Loan Guarantees |
| § 417.910 - Applicability. |
| § 417.911 - Definitions. |
| § 417.920 - Planning and initial development. |
| § 417.930 - Initial costs of operation. |
| § 417.931 - [Reserved] |
| § 417.934 - Reserve requirement. |
| § 417.937 - Loan and loan guarantee provisions. |
| § 417.940 - Civil action to enforce compliance with assurances. |