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).

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.

§ 438.74 - 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 - Medicaid managed care quality rating system.

§ 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 - XXX

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.