[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: 42CFR438.360]



[Page 235]

 

                         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 E_External Quality Review

 

Sec.  438.360  Nonduplication of mandatory activities.



    (a) General rule. To avoid duplication, the State may use, in place 

of a Medicaid review by the State, its agent, or EQRO, information about 

the MCO or PIHP obtained from a Medicare or private accreditation review 

to provide information otherwise obtained from the mandatory activities 

specified in Sec.  438.358 if the conditions of paragraph (b) or 

paragraph (c) of this section are met.

    (b) MCOs or PIHPs reviewed by Medicare or private accrediting 

organizations. For information about an MCO's or PIHP's compliance with 

one or more standards required under Sec.  438.204(g), (except with 

respect to standards under Sec. Sec.  438.240(b)(1) and (2), for the 

conduct of performance improvement projects and calculation of 

performance measures respectively) the following conditions must be met:

    (1) The MCO or PIHP is in compliance with standards established by 

CMS for Medicare+Choice or a national accrediting organization. The CMS 

or national accreditation standards are comparable to standards 

established by the State to comply with Sec.  438.204(g) and the EQR-

related activity under Sec.  438.358(b)(3).

    (2) Compliance with the standards is determined either by--

    (i) CMS or its contractor for Medicare; or

    (ii) A private national accrediting organization that CMS has 

approved as applying standards at least as stringent as Medicare under 

the procedures in Sec.  422.158.

    (3) The MCO or PIHP provides to the State all the reports, findings, 

and other results of the Medicare or private accreditation review 

applicable to the standards provided for in Sec.  438.204(g); and the 

State provides the information to the EQRO.

    (4) In its quality strategy, the State identifies the standards for 

which the EQR will use information from Medicare or private 

accreditation reviews, and explains its rationale for why the standards 

are duplicative.

    (c) Additional provisions for MCOs or PIHPs serving only dually 

eligibles. The State may use information obtained from the Medicare 

program in place of information produced by the State, its agent, or 

EQRO with respect to the mandatory activities specified in Sec.  438.358 

(b)(1) and (b)(2) if the following conditions are met:

    (1) The MCO or PIHP serves only individuals who receive both 

Medicare and Medicaid benefits.

    (2) The Medicare review activities are substantially comparable to 

the State-specified mandatory activities in Sec.  438.358(b)(1) and 

(b)(2).

    (3) The MCO or PIHP provides to the State all the reports, findings, 

and other results of the Medicare review from the activities specified 

under Sec.  438.358(b)(1) and (b)(2) and the State provides the 

information to the EQRO.

    (4) In its quality strategy, the State identifies the mandatory 

activities for which it has exercised this option and explains its 

rationale for why these activities are duplicative.