[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: 42CFR438.12]



[Page 217]

 

                         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.  438.12  Provider discrimination prohibited.



    (a) General rules. (1) An MCO, PIHP, or PAHP may not discriminate 

for the participation, reimbursement, or indemnification of any provider 

who is acting within the scope of his or her license or certification 

under applicable State law, solely on the basis of that license or 

certification. If an MCO, PIHP, or PAHP declines to include individual 

or groups of providers in its network, it must give the affected 

providers written notice of the reason for its decision.

    (2) In all contracts with health care professionals, an MCO, PIHP, 

or PAHP must comply with the requirements specified in Sec.  438.214.

    (b) Construction. Paragraph (a) of this section may not be construed 

to--

    (1) Require the MCO, PIHP, or PAHP to contract with providers beyond 

the number necessary to meet the needs of its enrollees;

    (2) Preclude the MCO, PIHP, or PAHP from using different 

reimbursement amounts for different specialties or for different 

practitioners in the same specialty; or

    (3) Preclude the MCO, PIHP, or PAHP from establishing measures that 

are designed to maintain quality of services and control costs and are 

consistent with its responsibilities to enrollees.