CFR /  Title 42  /  Part 417: Health Maintenance Organizations, Competitive Medical Plans, And Health Care Prepayment Plans

Section No.	Description
Section 417.1	Basis and scope
Section 417.2	Health benefits plan: Basic health services
Section 417.101	Health benefits plan: Supplemental health services
Section 417.102	Providers of basic and supplemental health services
Section 417.103	Payment for basic health services
Section 417.104	Payment for supplemental health services
Section 417.105	Quality assurance program; Availability, accessibility, and continuity of basic and supplemental health services
Section 417.106	Fiscally sound operation and assumption of financial risk
Section 417.120	Protection of enrollees
Section 417.122	Administration and management
Section 417.124	Recordkeeping and reporting requirements
Section 417.126	Scope
Section 417.140	Requirements for qualification
Section 417.142	Application requirements
Section 417.143	Evaluation and determination procedures
Section 417.144	Definitions
Section 417.150	Applicability
Section 417.151	Offer of HMO alternative
Section 417.153	How the HMO option must be included in the health benefits plan
Section 417.155	When the HMO must be offered to employees
Section 417.156	Contributions for the HMO alternative
Section 417.157	Payroll deductions
Section 417.158	Relationship of section 1310 of the Public Health Service Act to the National Labor Relations Act and the Railway
Section 417.159	Applicability
Section 417.160	Compliance with assurances
Section 417.161	Reporting requirements
Section 417.162	Enforcement procedures
Section 417.163	Effect of revocation of qualification on inclusion in employee's health benefit plans
Section 417.164	Reapplication for qualification
Section 417.165	Waiver of assurances
Section 417.166	Basis and scope
Section 417.400	Definitions
Section 417.401	Effective date of initial regulations
Section 417.402	General requirements
Section 417.404	Application and determination
Section 417.406	Requirements for a Competitive Medical Plan (CMP)
Section 417.407	Contract application process
Section 417.408	Qualifying conditions: General rules
Section 417.410	Qualifying condition: Administration and management
Section 417.412	Qualifying condition: Operating experience and enrollment
Section 417.413	Qualifying condition: Range of services
Section 417.414	Qualifying condition: Furnishing of services
Section 417.416	Qualifying condition: Quality assurance program
Section 417.418	Basic rules on enrollment and entitlement
Section 417.420	Eligibility to enroll in an HMO or CMP
Section 417.422	Special rules: ESRD and hospice patients
Section 417.423	Denial of enrollment
Section 417.424	Open enrollment requirements
Section 417.426	Extending MA and Part D program disclosure requirements to section 1876 cost contract plans
Section 417.427	Marketing activities
Section 417.428	Application procedures
Section 417.430	Conversion of enrollment
Section 417.432	Reenrollment
Section 417.434	Rules for enrollees
Section 417.436	Entitlement to health care services from an HMO or CMP
Section 417.440	Risk HMO's and CMP's: Conditions for provision of additional benefits
Section 417.442	Special rules for certain enrollees of risk HMOs and CMPs
Section 417.444	Restriction on payments for services received by Medicare enrollees of risk HMOs or CMPs
Section 417.448	Effective date of coverage
Section 417.450	Liability of Medicare enrollees
Section 417.452	Charges to Medicare enrollees
Section 417.454	Refunds to Medicare enrollees
Section 417.456	Recoupment of uncollected deductible and coinsurance amounts
Section 417.458	Disenrollment of beneficiaries by an HMO or CMP
Section 417.460	Disenrollment by the enrollee
Section 417.461	End of CMS's liability for payment: Disenrollment of beneficiaries and termination or default of contract
Section 417.464	Basis and scope
Section 417.470	Basic contract requirements
Section 417.472	Effective date and term of contract
Section 417.474	Waived conditions
Section 417.476	Requirements of other laws and regulations
Section 417.478	Requirements for physician incentive plans
Section 417.479	Maintenance of records: Cost HMOs and CMPs
Section 417.480	Maintenance of records: Risk HMOs and CMPs
Section 417.481	Access to facilities and records
Section 417.482	Requirement applicable to related entities
Section 417.484	Disclosure of information and confidentiality
Section 417.486	Notice of termination and of available alternatives: Risk contract
Section 417.488	Renewal of contract
Section 417.490	Nonrenewal of contract
Section 417.492	Modification or termination of contract
Section 417.494	Intermediate sanctions for and civil monetary penalties against HMOs and CMPs
Section 417.500	Effect on HMO and CMP contracts
Section 417.520	Payment to HMOs or CMPs: General
Section 417.524	Payment for covered services
Section 417.526	Payment when Medicare is not primary payer
Section 417.528	Basis and scope
Section 417.530	Hospice care services
Section 417.531	General considerations
Section 417.532	Part B carrier responsibilities
Section 417.533	Allowable costs
Section 417.534	Cost payment principles
Section 417.536	Enrollment and marketing costs
Section 417.538	Enrollment costs
Section 417.540	Reinsurance costs
Section 417.542	Physicians' services furnished directly by the HMO or CMP
Section 417.544	Physicians' services and other Part B supplier services furnished under arrangements
Section 417.546	Provider services through arrangements
Section 417.548	Special Medicare program requirements
Section 417.550	Cost apportionment: General provisions
Section 417.552	Apportionment: Provider services furnished directly by the HMO or CMP
Section 417.554	Apportionment: Provider services furnished by the HMO or CMP through arrangements with others
Section 417.556	Emergency, urgently needed, and out-of-area services for which the HMO or CMP accepts responsibility
Section 417.558	Apportionment: Part B physician and supplier services
Section 417.560	Apportionment and allocation of administrative and general costs
Section 417.564	Other methods of allocation and apportionment
Section 417.566	Adequate financial records, statistical data, and cost finding
Section 417.568	Interim per capita payments
Section 417.570	Budget and enrollment forecast and interim reports
Section 417.572	Interim settlement
Section 417.574	Final settlement
Section 417.576	Basis and scope
Section 417.580	Definitions
Section 417.582	Payment to HMOs or CMPs with risk contracts
Section 417.584	Special rules: Hospice care
Section 417.585	Computation of adjusted average per capita cost (AAPCC)
Section 417.588	Computation of the average of the per capita rates of payment
Section 417.590	Additional benefits requirement
Section 417.592	Computation of adjusted community rate (ACR)
Section 417.594	Establishment of a benefit stabilization fund
Section 417.596	Withdrawal from a benefit stabilization fund
Section 417.597	Annual enrollment reconciliation
Section 417.598	Basis and scope
Section 417.600	Applicability
Section 417.640	Payment to HCPPs: Definitions and basic rules
Section 417.800	Agreements between CMS and health care prepayment plans
Section 417.801	Allowable costs
Section 417.802	Cost apportionment
Section 417.804	Financial records, statistical data, and cost finding
Section 417.806	Interim per capita payments
Section 417.808	Final settlement
Section 417.810	Scope of regulations on beneficiary appeals
Section 417.830	Applicability of requirements and procedures
Section 417.832	Responsibility for establishing administrative review procedures
Section 417.834	Written description of administrative review procedures
Section 417.836	Organization determinations
Section 417.838	Administrative review procedures
Section 417.840	Applicability
Section 417.910	Definitions
Section 417.911	Planning and initial development
Section 417.920	Initial costs of operation
Section 417.930	Reserve requirement
Section 417.934	Loan and loan guarantee provisions
Section 417.937	Civil action to enforce compliance with assurances
Section 417.940	Statutory basis