Sie sind auf Seite 1von 2

§ 438.58 42 CFR Ch.

IV (10–1–09 Edition)

(2) If the MCO, PIHP, PAHP, or § 438.62 Continued services to recipi-

PCCM or the State agency (whichever ents.
is responsible) fails to make the deter- The State agency must arrange for
mination within the timeframes speci- Medicaid services to be provided with-
fied in paragraph (e)(1) of this section, out delay to any Medicaid enrollee of
the disenrollment is considered ap- an MCO, PIHP, PAHP, or PCCM whose
proved. contract is terminated and for any
(f) Notice and appeals. A State that Medicaid enrollee who is disenrolled
restricts disenrollment under this sec- from an MCO, PIHP, PAHP, or PCCM
tion must take the following actions: for any reason other than ineligibility
(1) Provide that enrollees and their for Medicaid.
representatives are given written no-
tice of disenrollment rights at least 60 § 438.66 Monitoring procedures.
days before the start of each enroll- The State agency must have in effect
ment period. procedures for monitoring the MCO’s,
(2) Ensure access to State fair hear- PIHP’s, or PAHP’s operations, includ-
ing for any enrollee dissatisfied with a ing, at a minimum, operations related
State agency determination that there to the following:
is not good cause for disenrollment. (a) Recipient enrollment and
(g) Automatic reenrollment: Contract re- disenrollment.
quirement. If the State plan so specifies, (b) Processing of grievances and ap-
the contract must provide for auto- peals.
matic reenrollment of a recipient who (c) Violations subject to inter-
is disenrolled solely because he or she mediate sanctions, as set forth in sub-
loses Medicaid eligibility for a period part I of this part.
of 2 months or less. (d) Violations of the conditions for
FFP, as set forth in subpart J of this
§ 438.58 Conflict of interest safeguards. part.
(e) All other provisions of the con-
(a) As a condition for contracting tract, as appropriate.
with MCOs, PIHPs, or PAHPs, a State
must have in effect safeguards against
conflict of interest on the part of State Subpart C—Enrollee Rights and
and local officers and employees and Protections
agents of the State who have respon-
§ 438.100 Enrollee rights.
sibilities relating to the MCO, PIHP, or
PAHP contracts or the default enroll- (a) General rule. The State must en-
ment process specified in § 438.50(f). sure that—
(b) These safeguards must be at least (1) Each MCO and PIHP has written
as effective as the safeguards specified policies regarding the enrollee rights
in section 27 of the Office of Federal specified in this section; and
Procurement Policy Act (41 U.S.C. 423). (2) Each MCO, PIHP, PAHP, and
PCCM complies with any applicable
§ 438.60 Limit on payment to other Federal and State laws that pertain to
providers. enrollee rights, and ensures that its
staff and affiliated providers take
The State agency must ensure that those rights into account when fur-
no payment is made to a provider other nishing services to enrollees.
than the MCO, PIHP, or PAHP for serv- (b) Specific rights—(1) Basic require-
ices available under the contract be- ment. The State must ensure that each
tween the State and the MCO, PIHP, or managed care enrollee is guaranteed
PAHP, except when these payments are the rights as specified in paragraphs
provided for in title XIX of the Act, in (b)(2) and (b)(3) of this section.
42 CFR, or when the State agency has (2) An enrollee of an MCO, PIHP,
adjusted the capitation rates paid PAHP, or PCCM has the following
under the contract, in accordance with
dcolon on DSK2BSOYB1PROD with CFR

rights: The right to—

§ 438.6(c)(5)(v), to make payments for (i) Receive information in accordance
graduate medical education. with § 438.10.


VerDate Nov<24>2008 09:41 Nov 03, 2009 Jkt 217182 PO 00000 Frm 00236 Fmt 8010 Sfmt 8010 Y:\SGML\217182.XXX 217182
Centers for Medicare & Medicaid Services, HHS § 438.102

(ii) Be treated with respect and with § 438.102 Provider-enrollee commu-

due consideration for his or her dignity nications.
and privacy. (a) General rules. (1) An MCO, PIHP,
(iii) Receive information on available or PAHP may not prohibit, or other-
treatment options and alternatives, wise restrict, a health care professional
presented in a manner appropriate to acting within the lawful scope of prac-
the enrollee’s condition and ability to tice, from advising or advocating on
understand. (The information require- behalf of an enrollee who is his or her
ments for services that are not covered patient, for the following:
under the contract because of moral or (i) The enrollee’s health status, med-
religious objections are set forth in ical care, or treatment options, includ-
§ 438.10(f)(6)(xii).) ing any alternative treatment that
(iv) Participate in decisions regard- may be self-administered.
ing his or her health care, including (ii) Any information the enrollee
the right to refuse treatment. needs in order to decide among all rel-
(v) Be free from any form of restraint evant treatment options.
or seclusion used as a means of coer- (iii) The risks, benefits, and con-
cion, discipline, convenience or retalia- sequences of treatment or nontreat-
tion, as specified in other Federal regu- ment.
lations on the use of restraints and se- (iv) The enrollee’s right to partici-
clusion. pate in decisions regarding his or her
(vi) If the privacy rule, as set forth in health care, including the right to
45 CFR parts 160 and 164 subparts A and refuse treatment, and to express pref-
E, applies, request and receive a copy erences about future treatment deci-
of his or her medical records, and re- sions.
quest that they be amended or cor- (2) Subject to the information re-
rected, as specified in 45 CFR § 164.524 quirements of paragraph (b) of this sec-
and 164.526. tion, an MCO, PIHP, or PAHP that
(3) An enrollee of an MCO, PIHP, or would otherwise be required to provide,
PAHP (consistent with the scope of the reimburse for, or provide coverage of, a
PAHP’s contracted services) has the counseling or referral service because
right to be furnished health care serv- of the requirement in paragraph (a)(1)
ices in accordance with §§ 438.206 of this section is not required to do so
through 438.210. if the MCO, PIHP, or PAHP objects to
(c) Free exercise of rights. The State the service on moral or religious
must ensure that each enrollee is free grounds.
to exercise his or her rights, and that (b) Information requirements: MCO,
the exercise of those rights does not PIHP, and PAHP responsibility. (1) An
adversely affect the way the MCO, MCO, PIHP, or PAHP that elects the
PIHP, PAHP, or PCCM and its pro- option provided in paragraph (a)(2) of
viders or the State agency treat the en- this section must furnish information
rollee. about the services it does not cover as
(d) Compliance with other Federal and
(i) To the State—
State laws. The State must ensure that
(A) With its application for a Med-
each MCO, PIHP, PAHP, and PCCM
icaid contract; and
complies with any other applicable
(B) Whenever it adopts the policy
Federal and State laws (such as: title
during the term of the contract.
VI of the Civil Rights Act of 1964 as im-
(ii) Consistent with the provisions of
plemented by regulations at 45 CFR
§ 438.10—
part 80; the Age Discrimination Act of (A) To potential enrollees, before and
1975 as implemented by regulations at during enrollment; and
45 CFR part 91; the Rehabilitation Act (B) To enrollees, within 90 days after
of 1973; and titles II and III of the adopting the policy with respect to any
Americans with Disabilities Act; and particular service. (Although this time-
other laws regarding privacy and con- frame would be sufficient to entitle the
dcolon on DSK2BSOYB1PROD with CFR

MCO, PIHP, or PAHP to the option

[67 FR 41095, June 14, 2002; 67 FR 65505, Oct. provided in paragraph (a)(2) of this sec-
25, 2002] tion, the overriding rule in § 438.10(f)(4)


VerDate Nov<24>2008 09:41 Nov 03, 2009 Jkt 217182 PO 00000 Frm 00237 Fmt 8010 Sfmt 8010 Y:\SGML\217182.XXX 217182