[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR1002.203]



[Page 1170]

 

                         TITLE 42--PUBLIC HEALTH

 

      GENERAL--HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

PART 1002_PROGRAM INTEGRITY_STATE-INITIATED EXCLUSIONS FROM MEDICAID--

 

                      Subpart B_Mandatory Exclusion

 

Sec.  1002.203  Mandatory exclusion.





    (a) The State agency, in order to receive Federal financial 

participation (FFP), must provide that it will exclude from 

participation any HMO, or entity furnishing services under a waiver 

approved under section 1915(b)(1) of the Act, if such organization or 

entity--

    (1) Could be excluded under Sec.  1001.1001 or Sec.  1001.1051 of 

this chapter, or

    (2) Has, directly or indirectly, a substantial contractual 

relationship with an individual or entity that could be excluded under 

Sec.  1001.1001 or Sec.  1001.1051 of this chapter.

    (b) As used in this section, the term--

    Exclude includes the refusal to enter into or renew a participation 

agreement or the termination of such an agreement.

    Substantial contractual relationship is one in which the sanctioned 

individual described in Sec.  1001.1001 of this chapter has direct or 

indirect business transactions with the organization or entity that, in 

any fiscal year, amount to more than $25,000 or 5 percent of the 

organization's or entity's total operating expenses, whichever is less. 

Business transactions include, but are not limited to, contracts, 

agreements, purchase orders, or leases to obtain services, supplies, 

equipment, space or salaried employment.



[57 FR 3343, Jan. 29, 1992, as amended at 63 FR 46691, Sept. 2, 1998]