42 C.F.R. PART 438--MANAGED CARE
TITLE 42--Public Health
CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER C--MEDICAL ASSISTANCE PROGRAMS
PART 438--MANAGED CARE
Subpart A--GENERAL PROVISIONS
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| Provisions that apply to PIHPs and PAHPs.
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| Information requirements.
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| Provider discrimination prohibited.
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Subpart B--STATE RESPONSIBILITIES
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| Choice of MCOs, PIHPs, PAHPs, and PCCMs.
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| Disenrollment: Requirements and limitations.
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| Conflict of interest safeguards.
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| Limit on payment to other providers.
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Subpart C--ENROLLEE RIGHTS AND PROTECTIONS
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| Provider-enrollee communications.
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| Emergency and poststabilization services.
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Subpart D--QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT
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| Elements of State quality strategies.
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| Availability of services.
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| Assurances of adequate capacity and services.
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| Coordination and continuity of care.
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| Coverage and authorization of services.
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| Enrollment and disenrollment.
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| Subcontractual relationships and delegation.
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| Quality assessment and performance improvement program.
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| Health information systems.
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Subpart E--EXTERNAL QUALITY REVIEW
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| Basis, scope, and applicability.
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| External quality review protocols.
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| Qualifications of external quality review organizations.
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| Activities related to external quality review.
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| Nonduplication of mandatory activities.
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| Exemption from external quality review.
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| External quality review results.
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| Federal financial participation.
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Subpart F--GRIEVANCE SYSTEM
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| Statutory basis and definitions.
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| Handling of grievances and appeals.
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| Resolution and notification: Grievances and appeals.
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| Expedited resolution of appeals.
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| Information about the grievance system to providers and subcontractors.
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| Recordkeeping and reporting requirements.
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| Continuation of benefits while the MCO or PIHP appeal and the State fair hearing are pending.
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| Effectuation of reversed appeal resolutions.
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Subpart G--[RESERVED]
Subpart H--CERTIFICATIONS AND PROGRAM INTEGRITY
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| Data that must be certified.
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| Source, content, and timing of certification.
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| Program integrity requirements.
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| Prohibited affiliations with individuals debarred by Federal agencies.
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Subpart I--SANCTIONS
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| Basis for imposition of sanctions.
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| Types of intermediate sanctions.
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| Amounts of civil money penalties.
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| Special rules for temporary management.
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| Termination of an MCO or PCCM contract.
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| Due process: Notice of sanction and pre-termination hearing.
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| Disenrollment during termination hearing process.
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| Sanction by CMS: Special rules for MCOs
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Subpart J--CONDITIONS FOR FEDERAL FINANCIAL PARTICIPATION
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| Expenditures for enrollment broker services.
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| Costs under risk and nonrisk contracts.
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