[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: 42CFR438.362]



[Page 235-236]

 

                         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.  438.362  Exemption from external quality review.



    (a) Basis for exemption. The State may exempt an MCO or PIHP from 

EQR if the following conditions are met:

    (1) The MCO or PIHP has a current Medicare contract under part C of 

title



[[Page 236]]



XVIII or under section 1876 of the Act, and a current Medicaid contract 

under section 1903(m) of the Act.

    (2) The two contracts cover all or part of the same geographic area 

within the State.

    (3) The Medicaid contract has been in effect for at least 2 

consecutive years before the effective date of the exemption and during 

those 2 years the MCO or PIHP has been subject to EQR under this part, 

and found to be performing acceptably with respect to the quality, 

timeliness, and access to health care services it provides to Medicaid 

recipients.

    (b) Information on exempted MCOs or PIHPs. When the State exercises 

this option, the State must obtain either of the following:

    (1) Information on Medicare review findings. Each year, the State 

must obtain from each MCO or PIHP that it exempts from EQR the most 

recent Medicare review findings reported on the MCO or PIHP including--

    (i) All data, correspondence, information, and findings pertaining 

to the MCO's or PIHP's compliance with Medicare standards for access, 

quality assessment and performance improvement, health services, or 

delegation of these activities;

    (ii) All measures of the MCO's or PIHP's performance; and

    (iii) The findings and results of all performance improvement 

projects pertaining to Medicare enrollees.

    (2) Medicare information from a private, national accrediting 

organization that CMS approves and recognizes for Medicare+Choice 

deeming. (i) If an exempted MCO or PIHP has been reviewed by a private 

accrediting organization, the State must require the MCO or PIHP to 

provide the State with a copy of all findings pertaining to its most 

recent accreditation review if that review has been used for either of 

the following purposes:

    (A) To fulfill certain requirements for Medicare external review 

under subpart D of part 422 of this chapter.

    (B) To deem compliance with Medicare requirements, as provided in 

Sec.  422.156 of this chapter.

    (ii) These findings must include, but need not be limited to, 

accreditation review results of evaluation of compliance with individual 

accreditation standards, noted deficiencies, corrective action plans, 

and summaries of unmet accreditation requirements.