42 C.F.R. PART 417--HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS
TITLE 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B--MEDICARE PROGRAM
PART 417--HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS
Subpart A--GENERAL PROVISIONS
Subpart B--QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS: SERVICES
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| Health benefits plan: Basic health services.
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| Health benefits plan: Supplemental health services.
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| Providers of basic and supplemental health services.
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| Payment for basic health services.
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| Payment for supplemental health services.
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| Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services.
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Subpart C--QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS: ORGANIZATION AND OPERATION
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| Fiscally sound operation and assumption of financial risk.
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| Administration and management.
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| Recordkeeping and reporting requirements.
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Subpart D--APPLICATION FOR FEDERAL QUALIFICATION
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| Requirements for qualification.
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| Application requirements.
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| Evaluation and determination procedures.
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Subpart E--INCLUSION OF QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS IN EMPLOYEE HEALTH BENEFITS PLANS
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| Offer of HMO alternative.
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| How the HMO option must be included in the health benefits plan.
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| When the HMO must be offered to employees.
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| Contributions for the HMO alternative.
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| Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway Labor Act.
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Subpart FREGULATION OF FEDERALLY QUALIFIED HEALTH MAINTENANCE ORGANIZATIONS
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| Compliance with assurances.
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| Effect of revocation of qualification on inclusion in employee's health benefit plans.
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| Reapplication for qualification.
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Subparts G-I--[RESERVED]
Subpart J--QUALIFYING CONDITIONS FOR MEDICARE CONTRACTS
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| Effective date of initial regulations.
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| Application and determination.
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| Requirements for a Competitive Medical Plan (CMP).
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| Contract application process.
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| Qualifying conditions: General rules.
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| Qualifying condition: Administration and management.
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| Qualifying condition: Operating experience and enrollment.
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| Qualifying condition: Range of services.
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| Qualifying condition: Furnishing of services.
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| Qualifying condition: Quality assurance program.
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Subpart K--ENROLLMENT, ENTITLEMENT, AND DISENROLLMENT UNDER MEDICARE CONTRACT
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| Basic rules on enrollment and entitlement.
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| Eligibility to enroll in an HMO or CMP.
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| Special rules: ESRD and hospice patients.
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| Open enrollment requirements.
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| Conversion of enrollment.
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| Entitlement to health care services from an HMO or CMP.
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| Risk HMO's and CMP's: Conditions for provision of additional benefits.
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| Special rules for certain enrollees of risk HMOs and CMPs.
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| Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs.
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| Effective date of coverage.
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| Liability of Medicare enrollees.
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| Charges to Medicare enrollees.
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| Refunds to Medicare enrollees.
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| Recoupment of uncollected deductible and coinsurance amounts.
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| Disenrollment of beneficiaries by an HMO or CMP.
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| Disenrollment by the enrollee.
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| End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract.
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Subpart L--MEDICARE CONTRACT REQUIREMENTS
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| Basic contract requirements.
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| Effective date and term of contract.
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| Requirements of other laws and regulations.
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| Requirements for physician incentive plans.
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| Maintenance of records: Cost HMOs and CMPs.
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| Maintenance of records: Risk HMOs and CMPs.
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| Access to facilities and records.
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| Requirement applicable to related entities.
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| Disclosure of information and confidentiality.
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| Notice of termination and of available alternatives: Risk contract.
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| Modification or termination of contract.
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| Sanctions against HMOs and CMPs.
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Subpart M--CHANGE OF OWNERSHIP AND LEASING OF FACILITIES: EFFECT ON MEDICARE CONTRACT
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| Effect on HMO and CMP contracts.
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Subpart N--MEDICARE PAYMENT TO HMOS AND CMPS: GENERAL RULES
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| Payment to HMOs or CMPs: General.
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| Payment for covered services.
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| Payment when Medicare is not primary payer.
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Subpart O--MEDICARE PAYMENT: COST BASIS
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| Part B carrier responsibilities.
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| Enrollment and marketing costs.
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| Physicians' services furnished directly by the HMO or CMP.
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| Physicians' services and other Part B supplier services furnished under arrangements.
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| Provider services through arrangements.
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| Special Medicare program requirements.
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| Cost apportionment: General provisions.
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| Apportionment: Provider services furnished directly by the HMO or CMP.
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| Apportionment: Provider services furnished by the HMO or CMP through arrangements with others.
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| Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility.
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| Apportionment: Part B physician and supplier services.
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| Apportionment and allocation of administrative and general costs.
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| Other methods of allocation and apportionment.
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| Adequate financial records, statistical data, and cost finding.
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| Interim per capita payments.
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| Budget and enrollment forecast and interim reports.
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Subpart P--MEDICARE PAYMENT: RISK BASIS
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| Payment to HMOs or CMPs with risk contracts.
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| Special rules: Hospice care.
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| Computation of adjusted average per capita cost (AAPCC).
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| Computation of the average of the per capita rates of payment.
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| Additional benefits requirement.
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| Computation of adjusted community rate (ACR).
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| Establishment of a benefit stabilization fund.
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| Withdrawal from a benefit stabilization fund.
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| Annual enrollment reconciliation.
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Subpart Q--BENEFICIARY APPEALS
Subpart R--MEDICARE CONTRACT APPEALS
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| Determinations subject to appeal.
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| Administrative actions that are not initial determinations.
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| Notice of initial determination.
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| Effect of initial determination.
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| Reconsideration: Applicability.
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| Request for reconsideration.
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| Opportunity to submit evidence.
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| Reconsidered determination.
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| Notice of reconsidered determination.
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| Effect of reconsidered determination.
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| Postponement of effective date of initial determination.
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| Designation of hearing officer.
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| Disqualification of hearing officer.
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| Time and place of hearing.
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| Appointment of representatives.
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| Authority of representatives.
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| Authority of hearing officer.
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| Notice and effect of hearing decision.
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| Reopening of initial or reconsidered determination or decision of a hearing officer.
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| Effect of revised determination.
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Subparts S-T--[RESERVED]
Subpart U--HEALTH CARE PREPAYMENT PLANS
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| Payment to HCPPs: Definitions and basic rules.
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| Agreements between CMS and health care prepayment plans.
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| Financial records, statistical data, and cost finding.
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| Interim per capita payments.
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| Scope of regulations on beneficiary appeals.
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| Applicability of requirements and procedures.
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| Responsibility for establishing administrative review procedures.
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| Written description of administrative review procedures.
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| Organization determinations.
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| Administrative review procedures.
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Subpart V--ADMINISTRATION OF OUTSTANDING LOANS AND LOAN GUARANTEES
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| Planning and initial development.
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| Initial costs of operation.
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| Loan and loan guarantee provisions.
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| Civil action to enforce compliance with assurances.
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