[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: 42CFR438.207]



[Page 227]

 

                         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 D_Quality Assessment and Performance Improvement

 

Sec.  438.207  Assurances of adequate capacity and services.



    (a) Basic rule. The State must ensure, through its contracts, that 

each MCO, PIHP, and PAHP gives assurances to the State and provides 

supporting documentation that demonstrates that it has the capacity to 

serve the expected enrollment in its service area in accordance with the 

State's standards for access to care under this subpart.

    (b) Nature of supporting documentation. Each MCO, PIHP, and PAHP 

must submit documentation to the State, in a format specified by the 

State to demonstrate that it complies with the following requirements:

    (1) Offers an appropriate range of preventive, primary care, and 

specialty services that is adequate for the anticipated number of 

enrollees for the service area.

    (2) Maintains a network of providers that is sufficient in number, 

mix, and geographic distribution to meet the needs of the anticipated 

number of enrollees in the service area.

    (c) Timing of documentation. Each MCO, PIHP, and PAHP must submit 

the documentation described in paragraph (b) of this section as 

specified by the State, but no less frequently than the following:

    (1) At the time it enters into a contract with the State.

    (2) At any time there has been a significant change (as defined by 

the State) in the MCO's, PIHP's, or PAHP's operations that would affect 

adequate capacity and services, including--

    (i) Changes in MCO, PIHP, or PAHP services, benefits, geographic 

service area or payments; or

    (ii) Enrollment of a new population in the MCO, PIHP, or PAHP.

    (d) State review and certification to CMS. After the State reviews 

the documentation submitted by the MCO, PIHP, or PAHP, the State must 

certify to CMS that the MCO, PIHP, or PAHP has complied with the State's 

requirements for availability of services, as set forth in Sec.  

438.206.

    (e) CMS' right to inspect documentation. The State must make 

available to CMS, upon request, all documentation collected by the State 

from the MCO, PIHP, or PAHP.