Subpart L. Subpart L—Managed Care

• General Provisions

  • SECTION § 457.1200 - Basis, scope, and applicability.
  • SECTION § 457.1201 - Standard contract requirements.
  • SECTION § 457.1203 - Rate development standards and medical loss ratio.
  • SECTION § 457.1206 - Non-emergency medical transportation PAHPs.
  • SECTION § 457.1207 - Information requirements.
  • SECTION § 457.1208 - Provider discrimination prohibited.
  • SECTION § 457.1209 - Requirements that apply to MCO, PIHP, PAHP, PCCM, and PCCM entity contracts involving Indians, Indian health care provider (IHCP), and Indian managed care entities (IMCE).

• State Responsibilities

  • SECTION § 457.1210 - Enrollment process.
  • SECTION § 457.1212 - Disenrollment.
  • SECTION § 457.1214 - Conflict of interest safeguards.
  • SECTION § 457.1216 - Continued services to enrollees.
  • SECTION § 457.1218 - Network adequacy standards.

• Enrollee Rights and Protections

  • SECTION § 457.1220 - Enrollee rights.
  • SECTION § 457.1222 - Provider-enrollee communication.
  • SECTION § 457.1224 - Marketing activities.
  • SECTION § 457.1226 - Liability for payment.
  • SECTION § 457.1228 - Emergency and poststabilization services.

• MCO, PIHP, and PAHP Standards

  • SECTION § 457.1230 - Access standards.
  • SECTION § 457.1233 - Structure and operation standards.

• Quality Measurement and Improvement; External Quality Review

  • SECTION § 457.1240 - Quality measurement and improvement.
  • SECTION § 457.1250 - External quality review.

• Grievance System

  • SECTION § 457.1260 - Grievance system.

• Sanctions

  • SECTION § 457.1270 - Sanctions.
  • SECTION § 457.1280 - Conditions necessary to contract as an MCO, PAHP, or PIHP.
  • SECTION § 457.1285 - Program integrity safeguards.