[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: 42CFR438.1]



[Page 209]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

                      Subpart A_General Provisions

 

Sec.  438.1  Basis and scope.





    (a) Statutory basis. This part is based on sections 1902(a)(4), 

1903(m), 1905(t), and 1932 of the Act.

    (1) Section 1902(a)(4) requires that States provide for methods of 

administration that the Secretary finds necessary for proper and 

efficient operation of the State plan. The application of the 

requirements of this part to PIHPs and PAHPs that do not meet the 

statutory definition of an MCO or a PCCM is under the authority in 

section 1902(a)(4).

    (2) Section 1903(m) contains requirements that apply to 

comprehensive risk contracts.

    (3) Section 1903(m)(2)(H) provides that an enrollee who loses 

Medicaid eligibility for not more than 2 months may be enrolled in the 

succeeding month in the same MCO or PCCM if that MCO or PCCM still has a 

contract with the State.

    (4) Section 1905(t) contains requirements that apply to PCCMs.

    (5) Section 1932--

    (i) Provides that, with specified exceptions, a State may require 

Medicaid recipients to enroll in MCOs or PCCMs;

    (ii) Establishes the rules that MCOs, PCCMs, the State, and the 

contracts between the State and those entities must meet, including 

compliance with requirements in sections 1903(m) and 1905(t) of the Act 

that are implemented in this part;

    (iii) Establishes protections for enrollees of MCOs and PCCMs;

    (iv) Requires States to develop a quality assessment and performance 

improvement strategy;

    (v) Specifies certain prohibitions aimed at the prevention of fraud 

and abuse;

    (vi) Provides that a State may not enter into contracts with MCOs 

unless it has established intermediate sanctions that it may impose on 

an MCO that fails to comply with specified requirements; and

    (vii) Makes other minor changes in the Medicaid program.

    (b) Scope. This part sets forth requirements, prohibitions, and 

procedures for the provision of Medicaid services through MCOs, PIHPs, 

PAHPs, and PCCMs. Requirements vary depending on the type of entity and 

on the authority under which the State contracts with the entity. 

Provisions that apply only when the contract is under a mandatory 

managed care program authorized by section 1932(a)(1)(A) of the Act are 

identified as such.